ML22230A110
| ML22230A110 | |
| Person / Time | |
|---|---|
| Issue date: | 08/02/1979 |
| From: | NRC/OCM |
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| References | |
| Tran-M790802 | |
| Download: ML22230A110 (139) | |
Text
RETURN TO SECRETARlAT RECJRDS t:..._._
NUCLEAR REGULATORY COMMISSION IN THE MATTER OF:
PUBLIC MEETING BRIEFING ON RESULTS OF IE INVESTIGATION OF TMI INCIDENT Place - Washington, D. C.
Dote -
Thursday, 2 August 1979 Pages 1 -
1 37 ACE. FEDERAL REPORTERS, INC.
Official Reporters 444 Nort h Capitol Street Washington, D.C. 20001 NATIONWIDE COVERAGE* DAILY Te!eohone :
(202 ) 347-3700
1 DISCLAIHER This is an unofficial transcript of a meeting of the United States Nuclear Regulatory Commission held on Thursday, 2 Auqust 1979 in the Commissions's offices at 1717 H Street, N. W., Washington, D. C.
The meeting was open to public attendance and observation.
This transcript has not been reviewed, corrected, or edited, and it may contain inaccuracies.
- The transcrtpt is intended solely for general informational I
purposes.
As provided by 10 CFR 9.103, it is not part of the formal or info~mal record of decision of the matters discussed.
Expressions of opinion in this transcript do not necessarily reflect final determinations or beliefs.
No pleading or other paper may be filed with the Corrnnission in any proceeding as the result of or addressed to any statement or argument contained herein, except as the Commission may authorize.
CR6283 i;
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1, UNITED STATES OF A.MERICA NUCLEAR REGULATORY COM.MISSION PUBLIC MEETING BRIEFING ON RESULTS OF IE INVESTIGATION OF TMI INCIDENT Room 1130 2
1717 H Street, N. W; Washington, D. C.
Thursday, 2 August 1979
,~.' ::
The Commission met, pursuant to notice, at 9:35 a.m.
- BEFORE:
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DR. JOSEPH M. HENDRIE, Chairman VICTOR GILINSKY, Comrni,ssioner RICHARDT. KENNEDY, Commissioner PETER A. BRADFORD, Commissioner JOHN F. AHEARNE, Commissioner ALSO PRESENT:
Messrs. Stello, Gossick, Gibson, Moseley, Allen, Martin, i and Bickwi t.
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.3 CHAIRMAN HENDRIE: May we com.e to order, please?
The commission meets this morning for a briefing on the results of the Office of Inspection and Enforcement investigation under the TMI accident.
Vic Stello, the head of the inspection office, will lead us through the briefing.
Vic 1 please go ahead.
Mr. Stello..
Thank you, Mr. Chairman.
First, let me introduce the people who are seated here at the table with me.
Starting to my far left~ Mr.
Martin; Mr. Allen; Mr. Gibson; Mr. Gossick just joined us; and Mr. Moseley; and myself.
I would also like to identify the investigators who wer~ part of the team -- who ware the team that jid the investigation at Three Mile Island.
And they were Me~srs.
Criswell, Fasano, Hunter, Kirkpatrick, Marsh, Martin, Collins, Donaldson, Essex, Ja£kson, Shakleton, and Uhaus.
I wonder it I Lould ask them to stand and be recognized..
I would like to express a note of appreciation on my behalf and the cornmLssion-'s behalf for the many long hours that the team put into the investigation.
It involved a long time away from their families and I +/-eel a special note of thanks is due.
I want to make that known now.
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CHAIRMAN HENDRIE: IJm sure the commission joins in thanking the members of the team for their efforts.
In view of the atmospheric condition, I offer the team members a special invitation to dejacket. before they melt down.
(Laughter.)
MR. STELLO: The way.in which we 1 re going about the presentation this morning, Mr. Chairman, 1~11 have some brie.f remarks and Mr. Moseley and Mr. Allen, the bullc of the presentations will be made by Mr. Martin first, covering the operational aspects dealing with those actions the licensee took during the initial 16 hours1.851852e-4 days <br />0.00444 hours <br />2.645503e-5 weeks <br />6.088e-6 months <br /> of the event u~
through 8.: 00 on the evening of March 28th.
(At 9:40 a.~., Commissioner Kennedy*enters the_rDom.)
MR. STELLO:
Fo 11 owing a pre s.e nt at.ion Mr. 'C3 ibs on will take on the actions taken by the licensee tn control release of the radioactive material from the off-site environment and to implement his emergency plan, for the period of the first three days up through midnight of March
- 30.
This report -
oh, the final note on the order of presentation will be to identify those items which we have characterized as potential items of non-compliance at this time.
(At 9.:40, Commissioner Gil.insky enters the room.)
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MR. STELLO: That was done intent ion a 11 y to avoid holding up publishing this report and the information in it.
So that all the other people who clearly have an interest in it will have it and those items that are identified as potential items of non-compliance will then be covered by Mr. Moseley at the conclusion of the presentation.
Very briefly, we.,,r.e not prepare.cl to take a pDsition as to wh_ich of those we will fina_lly conclude our items of non-compliance and our final enforcement act ion wi 11 have to await that f~nal review~ which will be some time in the future COMMISSIONER GILINSKY.: When do you see that taking place?
MR. STELLO.: I think we 1 11 probably need at least 60 days.
And I.,,11 want to_ihi~k very carefully about ~hether or not 1.,,11 want to se.e some additional information as we look through this.
I don-'t know.
Each of these items of non-compliance, there are in many of them arguments both pro and con as to whether there were.mitigating factors that,caused the licensee to do what he did.
And although there is a technical.violation of the license condition, he clearly did.the bett.er or safer thing.
I don*'t believe in that regard that it ought to then be listed as an J 1Jtem of non-compliance. 11 So we need to study them very carefully.
I hope to
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have it done in 60 days.
COMMISSIONER AHEARNE: Do you intend, or have you given consideration to the other investigations that are~
underway and what impa£t they might have on the _judgment?
MR. STELLO.: That was my point.
As we go through it, I may decide that we want to wait until other investigations are oYer.before. I r.e.ach that.final judgment.
And if tha tJ s true<=--
C0 MM I SSl ONER A.HEARNE.: Then it,might be more than 60 days.
MR. STELLO: Then it might be considerably more than 60 days.
More like six months.
But I will keep the
~ommission informed i.f I decide that thatJs what 1 s necessary and let the commission know that JJm going to wait until I get that information before reaching the final decision.
COMMISSIONER KENNEDY: Vic 9 let me go back to what I think you said.
You said that in many instances, these technical questions of non-compliance actually represented the course followed by the licensee, which was in the interest of safety.
Is that correct?
CHAIRMAN HENDRIE: Or could be.
COMMISSIONER KENNEDY.:
Could be.
MR. STELLO: In many instances, and I think as wi.11 be explained today, the reasons for him taking the action were
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because he believed that that was the ~orrect thing to do.
And in my view, l will want to waigh that very heavy before I decide an enforcement action should take place on an item such as that.
COMMISSIONER KENNEDY: Thank you.
MR. STEUO.:
Now the report clearly identifies various ar.eas of inadequacy with respect to equ.ipment performance, analyses~ training, and what have you.
I.think that many of these things you have probably heard before.
What will be new this morning will be a lot of the reasons behind why some of the actions were taken which was not available in previous presentations.
In spite of those inadequacies, though, I think that there.are proba_bly three points that I would l.ike to make +/-rom a broad.view of what I see.
And that s, first and foremost, th.at clearly, the accident was preventable. In spite of the inadequacies that we have found, it was clear that the
.basic equipment and the basic procedures that were there, had they been followed, the acc.ident could, indeed, have been prevented.
This does not say, and I do not wish to mean that, clearly, the operators took actions which were based on information that they had at the time they.had it, which were clearly wrong.
If they had, though, followed the basic procedures
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and used the equipment that was in place, this accident could have, indeed, been prevented.
A second point that I think is an important one,
.is the analysis that was per+/-ormed by the ad hoc group l ooki'l;J at the off-site exposuresc The results of. this investigation support that the conclusions that were reBched~ as a general principlev in terms of the health effects from off-site -- and weJll be getting into that.in quite a bit of detail during the presentation
- Finally, I think that what is.in the report provides an added bas-1s for the lessons learned, the items that Dr. Mattson and his report has come out with, things that ought to be done on other re act ors that.can m.ake a significant improvement in safety and cause these accidents to h3ve considerably less likelihood of occurring in the future.
I think as a general principle, what you find in
. th is report supports and adds further bas es to the lessons learned group.
Let me finally note what the report is not.
Remember that the report is a study of the licenseeJs actions.
There are other investigations going on.
Clearly, the two that ought to be mentioned -
the Kemeny Commission is doing its investigation, which w.ill be considerably broader in scope than what we have done, and your internal study group that you
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have appointed under Mr. Rogov.in also wi 11 be much broader in scope.
They clearly will cover some of the same material thatJs £overed in here; hence, there will be a need for me to want to reflect on whether that ought to be considered be+/-ore we take final action.
But they will clearly be brought.
They will.include the acti.ons that were taken by the designers, the vendors, the builders, the reviewers in various regulatory agencies and what they did.
on what se.ct ions So that those studies will need to go on.
COMMISSIONER AHEARNE: Can I ask a couple of questions you just described?
I r.ead through the introduction.and,th.e su":lrnar v e
of the report and I want to rtia k e sure that I unders~and your first point.
If I understand what you sa.id, why it was preventable is the followi~g -- that you now believe that enough is known on what actually did happen in the accident and.enough is known about what the operators did do in the accident, that you are able to reach the conclusion that had the operators followed the procedures that were spe.lled out, say the emergency procedures were adequate, had they followed the procedures as they were written and the equipment were allowed to perform as it was designed to perform and you believe it would have performed had it been allowed to, then the accident would have been prevented?
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11 l 2 13 14 15 16 17 18 19 20 21 22 23 24 25 10 MR *.STELLO: That.J> s correct.
CO MMI.SSIONER A.HEARNE.: But that presupposes, to me at least. the most important part of that is the assumption that at the present time, you now believe that we have enough information and understanding of what actually did happen through the period of the accident.
MR. STELLO: That.J's correct.
And there will be some specif~c BXamples cited that will make that point, I think, very clear.
\\'11th that, if there are no more questions, I*'..ll ask Mr. Moseley to make some remarks, toilowed by Mr. Allen.
COMMISSIONER KENNEDY: A point of clarification, Vic.
You said that the accident could have been prevente~.
- Is that the.word you mean, or J'mi tigatec 11 ?
Or both?
MR. STELLO.: Let me call what could *have been prevented, the ultimate damage to the core and release of fission products~
Whether or not the conditions that would have prevailed would have still been properly called an accident is not what I 1 m dealing with.
The relief valvB was not
_open.
That created at least the set-up for a small loss of coolant accident.
(At 9.:50, Commissioner Bradford enters the room.)
MR. STELLO: It probably would still have been ca-1led an accident, but I think that the damage that the accident,
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COMMISSIONER AHEARNc: As you say in your report, would have prevented the serious consequences.
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- STELLO: Yes.
Cm'iMI SSIONER GI LINSKY: Let me just pin this po int down that Mr. Ahearne is getting at.
You're saying that it was not --- that dama;;e could have been prevented if the operators had displayed ingenuity.
But simply, if they had followed their own procedures or the procedures established at that olant?
MR. STELLO.: Okay.
I don..,t want to steal some of the thunder.
Une of the procedures, and it will be identified in 14.--
- the pre sen~a ti on, deals wi t0 what the o peratDr is to do with 15 decreasing reactor cqolant pr~ssure.
Had he followed that 16 procedure, done what that procedurB said, it would have 17 prevented the accident.
18 He did not follow that procedure.
19 That..,s an example of what I mean.
There are 20 others.
21 CHAIRMAN HENDRIE: It might provide more illuminBtion 22 if we got down the line a little bit and, in effect, came 23 back to this question after a while.
24 MR., MOSELELY.: Okay.
Let me start by reminding you 25 of the negativeness of all investigations.
This investigation
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.J l 12 13 14 15 16 17 18 19 20 21 22 23 24 25 12 is not unique in that regard.
The report itself, of course, emphasizes those things that were wrong and the things that were not so wrong or were right get little attention.
And I wiil say that our presentation today is even more so in this direction because we are trying to summarize and to hit the high points and, of necessity, those tend to be negative points4 COMM.ISSIONER KENNEDY: flfhat does that add up to:?
MR. MOSELEY: It adds up to the fact that the impressions that one will get from listening to us and from reading the report emphasized the negative aspect beca~ss our investigation is trying to ferret out the negative asp9cts.
COM7vlISSIOr~ER KENNEDY.:. Are you suggesting that that impression ~ill be, thare+/-ore, perhaps, an unbalanced one?
MR. MOSELEY: It will be.
I. think that the total picture of the accidsnt needs to await completion of all of the investigative efforts and all the reports that will be generated.
So it would be premature to draw final conclusions in many areas based on what we have here today.
There is no new inform.at ion that will be presented here of a basic character.
There are many more details, and ther_e.is much more -- we have much more confidence now in the accuracy of some of the previous reported information.
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.I I 12 13 14 15 16 1*7 18 19 20 21 22 23 24 25 13 But we feel that there is no startling n.ew information that we will be presenting today.
COMMISSIONER AHEARNE: The SJODO reading was a li.ttle unusual?
MR. MOSELEY: I.wi.ll com.e ba.ck to, as Vic mentioned earlier, I will come back*to the ~terns at non-compliance.
And JJd like to ask, if we could, that WE save the discussion of those until then, rather than during the presentation that the other people will be making.
There are 35 potential items of non-comp"liance that are contained in the report.
We-'ve labelled them potential because we haven-'t taken the time to wash them out to make sure that they are, indeed, items of non-compliance.
Our focus has been on getting this Bctual report out so that it might be used* by those 'people who are continuing to look into this accident.
So, whereas, normally, we would h2ve done a.11 this before the r.eport was i.ssued, we"re sort of getting things nut of our nnrmal sequence, hopefully, to be helpful to other people.
COMMISSIONER BRADFORD: What is its status at th.is point as far as other people are concerned?
You-'ve passed it now to at once the Rogovin group and the President/s commission Others as well?
MR. MOSELEY:
It"s totally public. It-'s published
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.l l 12 13 14 15 16 17 18 19 20 21 22 23 24 25 14 as a NUREG-0600.
It-'s available to one and.a.11.
It has been supplied to the other groups that you have mentioned.
COM11':ISSIOi~ER GILINSKY: Let me just ask one more question.
Is this a summary volume or is this the entire report, because it doesn/t have back-up material.
MR. STELLO: It does not contain the interviews and there ar.e about 2DO interviews that have been transcribed.
And weJre going to have to deal with that because it's a considerable volume of paper.
COMMISSIONER GILINSKY: I haven*'t had a chance to look at it, the whole of it, carefully, but I don~t think that it contains various memoranda that might otherwise be in there, procedures at the plant and s8 on.
MR. STELLO.: Ph, no.
They.,,re.idenLified a*s* references but they a.re not ~ttached.
Let me ask B question: Are all the references except for the interviews in the PDR, do you know?
M;:?. STELUJ: The Public Document R.oorn.
MR. MARTIN! No, sir.
COMMISSIONER GILINSKY: It would seem to me that it would be use+/-ul to bind_them up in an appendix.
MR. MARTIN: If I may address that po int, we have collected the references together that have been used in support, or identified as references in that rBport, and
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.identified them in a_ddition to the total set of files that were developed during the course of the investigation.
Those references have been prep2red for shipment to Region 1 to be held with the historical file of all the documents that we reviewed during the course of the investigation.
MR. STELLO! Clearly, the intent is.to make th.em publicly available, bind them up, issue them as a NUREG, and make the 2000 copies that will be needed.
I want to go beck to the volume of paper and see if that-'s necessary.
Yes, weJll bind them up, have them in one place, and make sure that theyJre available.
MR. MOSELE--Y: vHth that, 1-'d like to,pass to Jim Allen.
- ALLEN: I., d 1 i k e to b r i e f 1 y co mm en t on the effort that was involved and the conduct o+/- the investigation during the four-month period of the investigation.
Practically, 31DO man-days of effort were expended by the investigators and the investigative team and its administrative support functions.
_ Of this, approximately 2400 man-days were expended by the team itself in conducting over 200 personal interviews or reviewing logs, charts, records, observing facilities and equipment, evaluating the results of these efforts, and in
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-15 16 17 18 19 20 21 22 23 2-4 25 16 the preparation of report draft-s *and the.fin.al investigation report.
The remainin~9DO man-days of effort were expended in the administrative support of the investigation by regional and headquarters administrative staffs.
Such support
.included.transcription and editing of over 3DO tapes and the drafting preparation an.cl reproduct.io.n of the final investigation report.
The investigation team itself consisted of 14 office of inspection and enforcement personnel assigned from various regi.onal offices and headquarter sta.ffs.
The team was constituted in two groups of 7 personnel each according to their area of expsrtise to examine the operation or radiological aspects of the* accident.
For a short period of time, the 14-man I&E team was assisted by several members of the staff of the affice of the inspector and auditor in conducting personnel interviews and establishing a system for editing taped transcripts.
During the entire period of the investigation, the team operated out of three mobile trai.lers located at the Three Mile Island observation center on the island itse.lf.
As Mr. Stello described earlier, the I&E investigation was limited to the following two aspects of the accidentJ those related to operational actions by the
.licensee during the period_ bet.ore the initiating event unt.il
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9 10 J l 1 2 13 14 15 16 17 18 19 20 21 22 23 24 25 17 approximately 8:DO p.m. on March 28 9 when primary coolant flow was re-established by starting a reactor coolant pump; and two, those steps taken by the licensees to control the release of radioactive material to off-site environs and to implement the emergency plan during the period from the initiation of the event until midnight on March 30th, which encompasses a period o+/- the major release of rad1oa£tivity_
At this time, Mr. Martin, would you please describe the operation?
.MR. MARTIN: May I have the first slide, please?
(Slide.)
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]0 1 I 12 13 14 15 16 17 18 19 20 21 22 23 24 25 18 By way partially of review, and partially to clarify some pointsv JJm going to have to review a number of issues.
I hope to do so very briefly, but just to recharacterize the nature of the accident and the sequence~ the summary !Jm presenting now does not differ in terms of the major event that took place thrnughout the 16-hour per.iod of the accident as covered by the Operations Group, from that that l presented in my briefing of May.
Therejs additional clarification on points but no major changes in terms of the major event that took place.
The conditions of the plant prior to the turbine trip is the reactor was operating at about 97 percent power, with the integrated contrpl system in full ord~r,
- automatic.
It was basically a normal, routine operational period of 97 percent power, normal makeup and letdown was enacted and used on the plant.
The plant was only in one _identified action statement under their technical specifications.
This was an open valve on the borated water storage tank with recirculation of its content.
ThereJs nothing unique or unusual about that set of circumstances.
CO MM I S S I ONE P. GI LI NSK Y :
Co u l d you exp l a i n t o m e what an action statement is?
MR. MARTIN:
In a technical specification, for example, you/11 have a limiting condition for operation.
6283 02 02 19 This is a mandatory requirement.
In the case of the borated 2
water storage tank, there ar.e a minimum of four conditions 3
which ~ust be met, the quantity of water in the tank. the 4
boron concentration, certain valves closed.
These arB a 5
series of conditions which are required to assure that that 6
particular system or component is in an operable state, 7
ready for use in the event of an emergency.
8 There are th.en action statements in the-;vent that 9
any one or more of those specific requirements or limiting.
10 condition for operation cannot be met, as in a.malfunction
.11 or as a compon.ent.breakdown or an electronic di.fficul ty, 12 something of that sort.
Depending upon the specific 13 component or malfun~tion, or the number of malfunctions
- 14 inv6lved, there ~s a defined action statement which says 15 that if.for example, a valve which normally would be 16 req~ired to be closed by the condition for opBration has to 17 be opened for some reason, there is a period permitted for 18 that valve to be open and still not considered to be in 19 violation of the basic requirement.
ThatJs the action 20 statement.
21 Therefore, in this particular case, with that 22 valve being open, they are permitted. up to 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> to 23 return that valve to a closed state, to return the B~ST back 24 to meeting the full requirements Df the limiting condition 25 for operation, and, for example, perhaps a simpler example
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.19 20 21 22 23 24 25 20 would be to diesels on a £ystem.
If one diesel breaks down, they have a period of time within which to get that sBcond diesel back into operating condition.
If it is not met, then they must take the series of subsequent steps which usually includes shutdown of the plant.
So, there was one such action statement in effect.
They were recirculatin; the BWST contents that would~ve expired at 3=DO p.m. on March 29th had the accident not occurred.
The_l'"_~_~_ctor-coolant system, unidentified leakage.*
There are leakage requirements on the reactor coolant system
_fo-rthe plant.
The *reactor coolEi"nt *system un.id.entified leakage was found by the investigation to actua.lly be.in Excess of technical specification limits due to a procudural error.
The limit on unidentified leakage is approximately, not Bpproximately, it is one gailon per minute.
When the procedure error was corrected by us and we recalculated the leakage of, I believe itJ~ approximately a week prior to the incident, the unid£ntified leakage values varied in the range of slightly in excess of 1 9pm to approximately 2-1/2 gmp.
So they were in excess of their unidentif.ied technical.specification requirements in that regard.
During the hours immediately prior to the shift,
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10 l l 12 1.3, 14 1.5 16 17 18 19 20 2l 22 23 24 25 21 we also noted during the review of the log book, and this would be 3-1/2 to 4-1/2 hour.s prior to the actual accident, the rate at which they were adding water to the makeup system, and to the reactor coolant system, increased
.substantial! y.
They typica.lly would add about 26DO gallons of water per shift to the operating plant, to make up the water loss rates, the major loss rate being through either the pilot-operated relief valve, the EMOV or one or more of the safety valves.
IJm not sure where precisely that leakage was coming from, but there was leakage coming from that area, and it was collected by their system.
It was within limitations; it was within the prescribed limits for identified' leakage, that is, it was.. i.d.entif.i.ed as to the general source, not the specific valve.
They were within their limits and as a consequence of that limit they had to make up about 26DO gailons per shift
- I t a ppe a rs that j us t before the a cc.i dent that leakage rate ju~ped to a rate of approximately 3600 gallons per shift.
That is, had the shift gone to completion, they increased the rate at which they were adding water.
Vie do not and have not been able to asc.erta.in the reason why that has occurred.
The records for that period of time are not aYailable, and of course the accident ensued for shortly thereafter.
S283 02 05 22 COMMISSIONER AHEARNE:
When you say the r.ecords 2
are not av.ai labl e, do you mean they.,.re gone?
3 MR. MARTINl The subsequent leakage rate 4
calculation that would be done on the following shift had 5
the accident not occurred, which would identify the sourcs, 6
never got to come to p.ass.
By that I mean there are no 7
records.
8 COMMISSIONER BRADF.C)RD:
But when you say, the 9
reason why, surely someone can explain to you why they.,.re 10 adding 3&00 instead of 26D0.
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- 14 15 MR. MARTIN:
We know that the reason they were adding it is because their makeup tank level as part of their volumB control system was showing the need to add wat.er.
What they needed it for, in the *sense o.f where th-e additional water was going, we a:re not able to determine.
16 17 18 19 20 COMMISSIONER BRADFORD:
You say in the report that opsration of the unit during the period March 25 to 28th had an unidentified leakage ratB in excass of a gallon permitted, is under consideration as a possible itsm of non-compliance.
Can you talk about that.consideration?
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CO MM I S S ION:: R AHEARNE:
They.,,re going to cover al 22 of those at the end.
23 COMMISSIONER BRADFORD-:
Okay.
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24 MR. MARTIN:
You wi 11 find that wording consistent 25 throughout the report.
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.22 23 24 25 23 COMMISSIONER BRADFORD:
That-'s what I wanted to think about.
COMM ISSI ONER AHEARNE.:
I th ink they intend to cover that.
COMMISSIONER BRADFORD:
Including the definition o.f the* phrase?
MR. MOSELEY:
Yes~.sir.
CHAIRMAN HENDRIE:
Vic noted at the beginning of the presentation that this report is presented in order to make the information in it available publicly well in advance of a determination of specific items of non-compliance.
ItJs going to take him about 60 days to shake those down, and that it~s possible that on some or all of those he*.might conclude that he would want to see the res.ults of some of the other investigati.ons that are going on, particularly, I_think, the CommissionJs own special inquiry, in which case it.would be longer.
So that when one comas here to items which are potentially items of non-compliance. that language is used just to indicate that this report does not constitute a set of findings on that.
COMMISSIONER BRADFORD:
What IJm interested in is, the sequence at least +/-rem consideration to determination.
CHAIRMAN HENDRIE:
Well, in the first instance the director-'s analysis and the staff~s analysis of the
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'_j 14 i 5 16 17 18 19 20 21 22 23 2-4 25 24 potential non-complian.ce items, of which there.is a list presented at the.back of the report, on which we-'11 hear more from Norm later on.
MR. MARI Ii.:
As you may recall~ in the disc u.ssion or briefing in May ~he exhaust tailpipe temperatures on both the safety valves and the EMDV were runnning above procedural limits.
I include that only as part of the general restatement of the general conditions.
Nothin~ has changed in that.
They were running above the pro~edural limits then established, and no new procedural guidelines had been established by the plant m2n2gement to inform the operators of what sort of collective actions to take in light of the fact that now the temperatures wera-close to the action levels, that their procedural guidance would have indicated the poiQt at which they should take action.
So this was an operating procedure which had, because of plant conditions, generally.fallen into a disuse kind of level.
The staff on duty met the technical specification requirements; in fact, they exceed the technical.specification requirements for staffing.
There was one shift supervisor assigned to Unit 2.
There was an additional shift supervisor assigned to Unit 1.
The reason for the additional shift supervisor was the fact that Unit 1 was coming out of a refueling outage and that was additional
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Normally there would have only been one shift supervisor et the plant.
COMMISSIONER AHEARNE.:
By staff on duty, you mean both plants together?
MR. MARTIN:
There would have been only one shift supervisor for both units, exce~t far this unique circumstance of Unit 1 coming out of a refueling outage.
That shift supervisor assigned to Unit 2 was in the office in the control room~ immediately adjacent to the control room at the time of the accident.
There were a shift foreman as required, who is a senior reacto.r operator licensed individual as is t.h.e shift supervisor;, there were two.control room operators in Unit 2 which is the normal sta.ffing for the singular Unit 2; and a*
total of eight auxiliary operator available at the plant.
And that does meet or exceed the sta+/-fing requirements.
Two of those auxiliary operators and the shift foreman, as you may recall from the May briefing, were working in the area o+/- the condensate polishing uni ts these are basically a dimineralization system for purification of feed water to the steam generator, and.they had been working there approximately.11 hours1.273148e-4 days <br />0.00306 hours <br />1.818783e-5 weeks <br />4.1855e-6 months <br /> at the time, for the purpose of trying to clear a trench for operation of resin~ and to clear a resin block that had occurred.
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Those three peopl.e specif~cally had been th.ere for about Jl hours?
MR. MARTIN.:
I_.,m sorry, that operation had been in effect for about J1 hours.
Those men had been there since the start of that shift which was at JJ.:DO p.m. the previous meeting.
(Slide.)
MR. MARTIN:
Okay.
The turbine trip occurred, as I~m sure we all can remember, at 37 seconds after 4:00 a.m. on that morning, on March 28th.
The turbine trip was caused by loss of all f.eedwater,. which I may not restate later on, but that loss of all feedwater on this plant is an analyzed accident for the facility, as it is for all such
.fa c il i t i es
- The cause of the f eedwater loss has not been definitely determined by this investigation.
We have looked at the work that has been done by the licensee, through the courses of our interviews with the staff, the people that were involved, the operators, the auxiliary operators and everyone else who has worked with those condensate polisher units.
We have not been able to a5certain the.exact cause.
We do feel the most probable cause is associated with some malfunction of the isolation valves on the condensate polisher uni ts, possibly, if not even probably,
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But we cannot, you know, definitely ascertain that was the cause.
COMMISSIONER KENNEDY.:
And this could have been associated, then, with what was going on to produce the blockage?
MR. MARTIN:
Yes, sir.
That was the hypothesis we presented back in May, and I think it is the most l.ikely or the most probable hypothesis and would probably stand
.,_, l,ne test of time.
But we cannot make a direct finding in that area.
COl,WdSSIONER.A.HEARNE:
But that particular point, I gather, Vic, is not necessary still for reaching your conclusion, that is, your concl,usion was even.if all feedwater had been lost, so that why 'it was lost' isn"t important to reaching the conclusion, that had procedures been followed, et cetera --
MR. STEUO:
That-" s correct.
MR. MARTIN:
We wanted to try to ascertain it, to be able to assure that there was no other surreptitious cause of the accident occurring.
But we were not able to do that in that regard.
All right, a detailed sequence of events, of course, is in Appendix 1-A. and I wi 11 not even presume to try to go through that or any portion of it, but if I may
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COMMISSIONER BRADFORD:
lo/hat did you mean by the phrase, surreptitious cause?
MR. MARTIN.:
I chose that word very p.oorly.
What we wanted to do, over the period of this investigation we have always been sensit.ive to the fact that there is a concern that the reason for the trip or the reason for actions taken or the reason +/-or the accident, the reason for the closed emergency feedwater valves, and a number of things was an overt act of an individual.
So we were sensitive to that possibility throughout t~ls entire investigation, and we have not found anything through0ut the*entire four months of interviews and other things that would lead us to believe that there was
.anything the.re that we should turn over to another investigating agen.cy, federal agency, that is, an improper act, an overt act, a criminal act, an Bet of sabotage.
Now, it would have been, I think, for the public good very worthwhile i+/- w.e had been able to ascertain absolutely that that was the cause, and in c2rtain areas we have not been able to do that.
But we have also not found anything that would lead us to believe that anything overt took place.
So I am
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.most likely hypothesis.
_ All right 9 if you recall the.basic a.sp.ects of the
.sequence and part of the initiating event is after the turbine trip, the El1\\0V failed to reclo.se -- that ultimately
~-----
resulted in a large lo.ss of reactor coolant system inventory.
May I have the next slide, olease?
(Slide.)
MR. MARTIN:
Then that caused-the particular parameter that caused a great deal of confusion and disruption to the operators and many of their a-ctions, is the unanticipated high indicated level in. the pressurizer.
And that fact will pervade the actions that the operators take throughout the course of the event.
The continuing high level of the pressurizer despite a loss of inventory, the reactor coola~t system pressure did continue to drop during the early phases to a low point of about ~60 psi was reached at about 2.3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br />.
That was the point at which the EMOV was diagnosed as being open, the EMOV was closed and reactor coolant pressure system sta.rted to recover.
The rea.ctor coolant pumps were tripped at 74 and 101 filinutes into the accident,
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As a result.of the conditions that -.existed at the time the pumps were tripped COMMISSIONER GILINSKY.:
Could l ask you about the reactor coolant pumps?
As I read the report, it seems to be saying that they should have been tripped at some earlier point; is that right?
MR. MARTIN:
May I ask you to defer that question?
I am going to treat that one specif ica_ll y in about one more slide.
I.,.11 be coming to that point~
The open EM.OV, as you recall, was isolated at 2.3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br />.
By 2-1/2 hours, the core had been uncovered to some degree, fLssion product released and hydrogen generated because of the metal-water reaction.
And in the remainder of the sequence, let me just generally characterize it.
There was a period of time in which the emergency staff attempted to repressurize to fill the loops, to be able to establish natural convection and to be Eble to run coolant pumps.
They then depressurized the system to attempt to usB the decay heat system.
And then, in the final 2-1/2 hours or so of the 16 hour1.851852e-4 days <br />0.00444 hours <br />2.645503e-5 weeks <br />6.088e-6 months <br /> accident sequence, they repressurized the system and finally sent a reactor coolant pump into operation.
COMMISSIONER AHEARNE:
I gather that there are no significant new developments in.chronology?
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That.,, s correct.
From that standpoint of the significant sctions and the general course of events that was chosen by the emergency team that was directing activities, there we~e no major changes from our May presentation.
May I have the next slide, please?
C Slide.)
MR. MARTIN:
When we looked at the shift crew actions, those th_inqs that we considered to be the most significant shift crew actions that o~cur, I think I would like to ask you to recognize the first two items that we have on the slide ~nd that is, I believe mind-set was the term that was used in the introduction.
I think i~ adequately characterized --
COMMISSIONER GILINSKY:
Could you just say 2 word 2bout the training of the operators who were on duty at the time, as a preface to this.
MR. MARTIN:
Okay.
If I include the shift supervisor a.ssigned to the Unit, the t.'110 control room operators and the shift foremen, those -- I.,rn trying to go down all of those men, those four individuals that I described, licensed operators assigned. specifically to Unit 2 were ex-Navy--trained indiv.iduals.
They had gone through an abbreviated auxiliary operator train.in9 program because of their extensive prior Navy experience.
They went through
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IJrn trying to run down th.e list very quickly.
COMMISSIONER GILINSKY:
Were they trained on simulators?
MR.. MARTIN.:
Y.es. it was the complete training program which included training on the simulator.
COrv~MISSICJl~ER AHEARNE.:
You said that they had attended from for five to nine weeks?
MR. MARTIN; They had a complete training program.
None of them had rec ie ve d an a bbre vi at ed course.
When I mention the abbreviated course, ~here is a progre'ssion f:rom auxil i'ary operator to control r.oom
'
- ope r at or, and for p e o pl e w it h pr i or nu c l ear exp er i enc e COMMISSIONER 'GILINSKY.:
That have previously been operators in the Navy?
MR. MARTIN.:
Either in the Navy nuclear program or at another reactor but that is the only plac.e where the abbreviation occurs, not in the control room operator.
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I.n 1 ooking through t.he list in your document, it appears that they all hav.e a very extensive amount of experience.
MR. MARTIN.:
Yes 9 sir.
I. think.the total
.experience of those fnur people in that room would probably total 20 or so man-years of experience at TMI and~ometh1ng close to 40 to 45 man-years of total applicable nuclear experLence.
CO/{J,nSSIONER KENNEDY.:
How would this be classed, would you judge, with the average plant?
MR. MARTIN:
I saw nothing uniquely increased or decreased in terms of the total amount of experience available on the shift at that time.
COMMISSIONER KENNEDY:
So it--'s fairly typical?
MR. MARTIN~
I would*say so.
Yis, sir, based rin
.my experienc.e.
L think that that-'s a correct statement?
All right.
W.i th r.egard to the shift crew act.ions, recognizing the mind-set and that they were repeatedly trained to avoid solid pre5surizer operation at all times, never to take the plant solid where you lose the ability of the bubble to mitigate pressure transients, and the second one -- part of their training was that whenever there is an RCS.inventory loss, they would expect to see a reducing level or a reduction in lev.el.in the pressurizer.
Therefore, if they see reduction in level, they can couple
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So with ~hat mind-set CCHliMLSSIONER GILINSKY:
When you say ntrained 11,
does that include 11 instructed 11 in the pr.ocedures on th-1s plant?
MR. MARTIN:
This would include instruction in procedures *.. This would include the instruction on the simulator.
This would include class instruction.
COMMISSIONER GILINSKY:
Yfore.there specific written.instructions on_ this plant?
MR. MARTIJf:
I believe the answer is yes.
I cannot recall it off the top of my head.
COWiiISSIONER GILINSKY:
Does that mean, in effect, that there we re.conflicting.instructions on keeping our pressure inj~ction on and avording pressurizer -
MR. MARTIN:
No, sir.
I would not say so.
I would say the guidance, as it was presented in those procedures, was where to achieve pressurizer levels.
But the clear primary instructions addressed recovery of pressure and recovery of level in the reactor coolant system in the event of a loss of coolant system pressure.
I do not bel.ieve -- in my view I would not consider them to be conflicting requirements in the way in which they were presented in the procedure that the men were using at that time in recovering from this particular accident.
CHAIRMAN HENDRIE:
In terms of the written
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MR. MARTJN:
Yes, in terms nf the written procedures they utilized.
CHAIRMAN HENDRIE:
But apparently in terms of the shift w.ork practices and operating practices, they did focus very heavily on that pressurizer level to the exclusion of apparently other indications.
MR. MARTIN:
That 1 s correct, sir.
That was a primary para~eter that their training, not their procedural requirements as such, but their training led them to always key on pressurizer levels
- COM:~ISSIOi'~ER AHEARNE:
1-'ias the training that explicit, or it w.ent so far as to do just what you s3id?
MR. MARTIN:
I would say it was consistent and explicit. It was consist~ntl~ reiter~ted and'explicit.
COMMISSIONER AHEARNE:
But that was a dominant instrument.
MR. MARTIN:
Yes, sir.
So there were four conditions, we believe, that contributed to the sequence of the accident as it occurred.over the 16 hour1.851852e-4 days <br />0.00444 hours <br />2.645503e-5 weeks <br />6.088e-6 months <br /> period.
Now, I think at this point I would like to stress that we will discuss through this what the rationale of a number of the operators were in taking the actions that they took, but not that this was knowingly or intentionally done to aggravate the accident but, we believe, did in fact aggravate the
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Okay, the first one has to be the throttling of the high pressure injection to ~inimu~ values.
From the onset of the accident and for a period of three and a half hours, the operating staff reduced high_pressure injection flow to a iinimum.
We fo0nd that the average flow over this three and a half hour period was a net input to the reactor coolant system of 70 ga.llons per minute from the borated water storage tank.
In fact, if one subtracts the two periods during that three and a half hour time frame at which the high pressure injection was operating fully automatically and therefore at maximum output rate of approximately 1000 gpm, the net flow for the remainder of that period for the majority of the thiee and a half hours was a*ctua._l1y trimmed down to approximately 25 gpm.
So the operators had seYerely throttled high pressure injection flow for about three and a half hours.
The second_.item was the continued operation of the reactor cool ant pumps be low pressure 1 imi ts.
The same procedure requirement that the operators were using at that point called for tripping of the reactor coolant pumps in a situation of dropping reactor coolant system pressure at 1200 psi decreasing.
When pressure is dropping, they ought to trip the pumps before passing through 12DO psi.
COMMISSIONER GILINSKY:
Now this is a point you
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MR. MARTii~~
That-"s correct, sir.
COMMISSI01'l"ER AHEARN.=:
It"s a similar point~
though, that Mattson made to us.
MR. MARTIN:
Now their procedural requirements are that they should have tripped the pumps.
Now that condition was satis.fied approximately 15 minutes after :.he start of the accident.
Now 9 I do understand and I am aware that there is some debate going on as to the advisability of continuing or not continuing to operate those pumps.
I know that an I&E bulleting has been issued recently relative to that matter, and from that standpoint what we are addressing, are not trying to enter into that particular de~ate, ~as that in this condition tMey had a reactor I
.c oo l ant s y st em pr e s sure lo.s s under 'ti a y
- They had a procedural requirement at that ~oint that they should have tripped the pumps, and that point was reached within 15 minutes.
COM?,\\ISSICHJER GILINSKY:
lbw, ho*.: v:ould it ::ave been beneficial to trip the pumps?
MR.
MARTir~:
If I may address -
by the coi1tinued operation of the pumps.
And based on the flow indications that were received, it would appear that there was a distribution of voids by continuing to operate the pumps in a saturated fluid condit.ion.
And that distribution
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£on+/-inuBd throughout the.reactor coolant system.
As soon as they tripped the pumps, i~ would appear that all those voids coalesced, and they immediately lost natural convection possibility and -immediately started a tem;:>erature transient.
CO MMI SS I.ONER AHEARNE:
But if they had t r_ipped --
while youJre raising that they didnJt follow the procedure, at least the implication or inference is that had they followed the procsdure, it would have been advantageous.
And so, what is it that would not.have -- or what is it that Would have happened that would have been advantageous had they trioped them at that 15 minute po.int?
MR. MARTIN:
I*'m 9ettin9 into an area where I would_really feel much more co~fortable if I were supported by substantially more analytical work.
We do know physically what occurred.
To conjecture what might have occurred, from my standpoint as a field investigator CDM7v'i ISSI ONER AHEARNE.:
Okay.
Then I would turn to Vic, because I think this begins\\ at least -- it sounds like it-'s ge.tting.into the area that you referred to in the beginningy had. they followed the procedures.
MR. STELLO:
This isn"t what I h.ad in mind when I made that statemBnt, however.
This is an example of what I have in mind when I suggest that I want to study very hard whether this ought to be an item of non-compliance.
You raise a question -
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So the point here is *that they didnJt follow the procedures, but youJre not yet sure whether ~r not --
MR. STELLO:
Had they not f o 11.ow.ed the p_roc edures.
would the accident have been more severe or le.ss severe is the Lssue.
COMM ISSI.ONER AHEARNE:
And you.,. r.s not sure yet?
MR. STELLO:
And I don-'t. think there is an answer to that question, nor do I think we will be able to answer the question.
Because again, you have to ask, well, if the operator had tripped the pump, would he have done so11ething differently than what he did do.
Si~ce he now will have been presented with some new facts and information would hav~ been different, would he have done something different?
And that-"s so.
COMMISSIONER AHEARNE,:
But then as the point youJre making that this is an item* where they d.idn.,..t follow procedures and the significance is totally restricted to that, that they didn.,t follow procedures --
MR. STELLO:
They didn.,t follow the procedures, and this is an example of one which is a potential item of non-compliance.
They kept the pump running.
There*,.s a substantial argument that can be made that says the fact that the pump was running in this instance clearly kept the core cool.
The forced circulation mode, at least instincts
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CO/./;iV:ISSIONER GILINSKY.:
I th.ought that up until now we were told that the operator should not have turned off the pumps when they did.
Sometime later on.
MR. STELLO.:
And subsequent to that, we./ve been going back and looking and asking the question and have issued new instructions suggssting that they ought to trip the pumps early, with some other provisions.
COMM I.SS I ONER GILI NSKY:
Let me go back to this list.
You've got it listed under conditions which contributed to the accident, and it/s in with throttling the high pressure injection and failure to isolate.
MR. STELLO:
v-,e discussed this yesterday,and carr.e to the conclusion we were hard pressed to say it contribUted to the accident.
And I was trying to leave you with the conc.lusion that had they.not tripped it, I don-J't believe you can say that it would have been the accident less or more severe, if they had tripped it 15 minutes --
MR. M.OSELEY:
I think when we talked about it yesterday, Vic, we concluded that it~s appropriate to leave it in that list because, as a matter of fact, the core damage did follow shortly after that and, indeed, tripping it at that point in time did cause the bubble formation.
COMMISSIONER.A.HEARNE:
But Norm, this is 15
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Are you saying the core damage occurred shortly after that?
MR. 1\\/iDS=Li::Y~
No.
dhat the statement says is I
guess the stBtement is misleading -- it is misleadin;.
CHAIRMAN HErWRIE.:
The pumps were tr.ipped 100 times COMMISSIONER AHEARNE:
Yes, I know.
But at this point that the procedure would have had it trioped. was it 15 minutes?
CHAIRMAN HENDRIE:
Yes~ just so.
MR. STELLO.:
And you cannot conclude that had they tripped them at 15 minutes, that the accident would have been either more or less severe.
CO Miv\\LSS IOr~ER AHEAi-rnc !
- so it.,. s sort of a three prime MR. STELLO:
When.we went through it yesterday, we were arguing as to whether it ought to or ought not to be, and we left it in there, quite frankly, because I don.,.t think we really had enough time to change the slides and make more copies.
CHAIRMAN HENDRIE~
Good.
Onward.
I don.,.t want to slight anything, but --
MR. MARTIN:
I see the time is moving.
The third item was the failure to isolate the EMOV in l.ight of the evidence that was available.
The area that
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However, we could not ascertain during the course of the investigation an adequate explanation, in our view, as to why it took as long as it did in light of the evidence, which was dropping r.ea~tor coolant system pre_ssure, the ruptured disk on the reactor coolant drain tank, and the like.
CO/vi7JiISSIONER AHEARNE.:
You.,re saying that there were enough secondary indications that should have l~d-the opera~ors to conclude that the EMOV was open?
MR. lv.ARTIN.:
Yes.
Okay.
The it.em v.;as the faii.ure to establish the conditions for natural circulation between the tripping of the first set of reactor cooling pumps and the second set of reactor cpoling pumps.
That was, again, during the period during which high pressure injection was
.maintained a minimal amount, and it was a period in ~hich there was a constant degradation of the flow, reduction in the indicated flow rate out of the second set of reactor coolant pumps.
The operating sta_ff was addressing, looking towards the putting of the pumps or putting the plant into
.natural circulation.
But at that particular period of time 9 the
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COMMISSIONER GILINSKY:
Do you believe they could have gotten to natural circul3tion at that point?
CHAIRMAN HENDRIE:
Let.,,s ask first whether they could have gotten the system aoparently within the pressure-tern pe ra ture range. The system had voids. Whether in fact you could have made the circulation go is a second question *.
MR. MARTIN:
I would prefer to answer that in such a way t~at I really ca~not.
I don't know if they would have been able to.
But had thiy increased high pressure injection substantially to bring it into the temperature-pre.ssure bounds that were required, they may have been presented with new evidence, such as the behavior of the system, which indicates that the plant was not solid, as they thought it was -- a different pressure behavior, therefore perhaps a.different level behavior, a different temperature behavior -- and then once given that set of circumstances, I donJt know how the operators would have acted.
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-A-4 But the point was that we~re trying to stress here is that they did not take -- although they were aniticipating and moving toward going into natural convection -- they did not take the steps to bring it into the appropriate bounds, to successfully establish it.
Whether or not it would have been possible, I can~t really
.address,, dep..ending on what actions they would hav.e taken.
Basically, they tripped the pumps, and they just hoped that natural circulation would follow.
Yet they were outside the bounds for it to have done so.
COMMISSIONER AHEARNE:
But is D, then, substantially different than A, 8, and C?
MR. MARTIN:
Yes, sir, because of the time frame.
That is, they we re moving in between the tr i p;::,ing o_f the two sets of pumps.
They were moving towards a condition in which they were thinking in terms of establishing natural circulation, and they did not take steps to do so.
COMMISSIONER AHEARNE:
But the steps that you pointed out they might have taken is, essentally, if they didn*'t do A MR. MARTIN:
It is hard for !"!le to keep from interrelating all oi these, because clearly high pressure injection being throttled to a minimum would have been related to D as we_ll.
All right.
Now there were two actions that
5283 03 1.3 i ec 2
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CHAIRMAN HENDRIE:
There are other things connected to system pressure, so it isn~t just high pressure injection that you might have exercised to try to get within the natural circulation operating envelope.
MR. MARTIN:
There were two actions taken by the operating staff in the early hours that, as we can see, did not contribute at a.11 to the accident as it evolved.
We point them out because we consider them to be essentially two significant events, had a different course of action evolved suddenly and unexpectedly.
The first is that after automatic initiation of high pressure injection, the system cails for the emergency diesel to start _up, and should they be n£eded to provide electrical ~ower, they would already be operating and ready to run.
They did so.
They started with the first high pre~sure injection, and they ran for 28 minutes.
They then shut down the diesels, as is appropriate under procedural controls.
They shut down the diesels because they were running-unloaded.
Therefore, they were running a risk in putting them in a position where they would not start again if they were needed for an unloaded operation.
But when they shut the diesels down, they did not reset the start mechanism.
So 9 as a res~lt, those diesels
.could not ha v e started on au tom at i c in i t ia t ion, had the r e
6283 03 14 ec 2
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- 15 16 17 1 8 19 20 21 22 23 24 25 46 been a need for them during a powsr failure, if a power failure had occurred.
Now, none had occurrBd throughout the course of the accident.
They did have normal power.
If there were one to have occurred, thB diesels would not have started and would not have picked up the load.
That occurred about 30
.minutes into the incident.
About.five and a half hours into the 1ncident, an engineer, I believe it was, spotted the flag indicator showing that the diesels were in this rather u~usual condit.ion and, therefore, not capable of starting.
And it was decided that they would put them at least into a position where they could manually start them.
So they took certain actions.
CHAIRMAN HENDRIE1 From the control room, that is?
MR. MARTIN:
Fr6m the control room, yes,* sir.
COMMISSIONER AHEARNE:
Why didn-'t th.ey put them back into the automatic start?
MR. MARTIN!
Why?
At the five and a half hour point, at about 9:30 in the morning, the reason they didn~t put them back to the automatic start mode was that they felt that their power grade was very reliable.
They didn't have power.
They didn-'t need the diesels at the 9:30 time frame to shut the diesels down, if they started, means sending a man out to the auxiliary building when they auto-start on a high pressure injection system.
They can~t stop them in the
5283 03 15 ec 2
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13 14 15 16 17 18 l9 20 21 22 23 24 25 47 control room.
They must send a man to the auxiliary building, _which by then was radioactive.
COMMI.SSICHER AHEA~Nc:
So 1:..rhen they stopped them at the 30 minute point, it was by sending someone down?
MR. MARTIN:
That~s correct.
Now we have not as.certained who stopped. them at the 30 minute point, who order..ed them to shut..down, and who order.ed the:n to be put in that position.
I can only address the rationale that was given at the 9J30 frame, 9:30 in the morning, when they gave manual start capability back into the control room.
COMMISSIONER GILINSKY:
\\'/hat would have been the significance o+/- the unavailability of. the diessls?
MR. i',\\ARTLt:
If there had.been. a pov:er outage, it would have requ~red someone to gq down, reset the"dissel fuel racks, get the diesels started, and then let the system start to pick up itself.
It would have introduced a time lag into those safety related systems that are fed from the diesels over and above what would normally be ~ncluded in a normal startup.
COMMISSIONER GILINSKY:
That couldnJt be done from the control r~om?
MR. MARTIN:
No, sir, not when they start under emergency starting conditions of that sort.*
Then the only way they can be tripped is from outside, and then miJht be reset from outside to return the capability for automatic
- 5283 03 16 48-ec start back into the system.
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,1 49 COMMISSIONER BRADFORD:
Let me take you back to 3 (b) for a minute, failure to establish conditions for natural circulation.
You concluded in the report that the people in the control room were in fact not trained in the methods of establishing natural circulation.
That I s correct, they had not received specific training.
COM.MISSIONER BRADFORD:
But what really contributed to the accident was less their failure to do it than their failure to be trained to do it.
J11R. MARTIN:
I think both contribute to the actions i
i that were taken.
Perhaps that would be conjectural on my part. i They ~re both facts that, one, they did not take the actions, and two, they were not trained.
And I would not want to rank the relative contributor of one to the other.
COMMISSIONER BRADFORD:
I ask it only because of the overriding conclusion of what's really disturbing here is the failure of the operators to do certain things.
If this is one of those things, if the report separately concludes that they weren't trained to do it, then what may be really disturbing may reach back into the training program, Dather than simply lie with these particular operators.
MR. MARTIN:
I think training has a very substantive role in this accident.
I think certainly the mind set with regard to pressurizer level that we discussed previously is
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So training, I think, 2
plays a very significant role, the training of the operators 3 1 p 1:iys a very significant role in the actions that they took.
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COMMISSIONER GILINSKY:
Well, did the operators 5 I understand that they were outside the natural circulation 11 !,
II 6 11 regime, the pressure-temperature region in which you cou 1l. get
,1 7
natural circulation?
8 Ii MR. !vlARTIN:
I know a number did.
I also k now that Ii s-Ii some of the people in the control room had pulled the NPSH 11 lo :,1 curves to the pumps because they were worried about suction I!
1; i11: pressure.
I should address it in the report, and what I'm 12 I i
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afraid of doing is giving you a very pat answer and not in exactly the wording wh~ch is used inside.
COJv'.!MISSIONER GILINSKY:
You said earlier that they turned off the pumps and hoped, was I think the word you used.
MR. MARTIN:
There was basically a hope that natural circulation would occur.
COMMISSIONER GILINSKY:
Knowing they were outside the regime for natural circulation?
MR..MARTIN:
Could I turn to one of the members, who I think might answer better, and just remind me whether or not they had -- Norman or Tim, did they have the PT curves out for natu al circulation?
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Yes, they did.
The pressure-temperature relationship for tripping the reactor coolant pumps
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So they did have the appropriate table.
COMMISSIONER BRADFORD:
But these are people~-you say the shift personnel associated with the accident had not received specific training on the natural circulation aspects on the site, either at the facility or at the simulator.
So who knows what they recognized under the pressures of the accident.
MR. IY.LARTIN:
It is true they did not receive specific training.
CHAIRMAN HENDRIE:
Had the unit ever been on natural circulation cooling before; do you know?
MR. :MARTIN:
I don't know that, sir.
I wou J:i assume II io I at least during the preoperational test program, but that's I
19 i an assumption.
i 20 ii COMMISSIONER AHEARNE:
Did your group make any 21 I judgment I
you pointed out there were a number of procedures 22 ii they didn't follow, and had they followed these procedures the Ii 23 [\\
serious consequences wouldn't have occurred.
Do you know A
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Ii 52 training that they had been given, what would have happened?
That's I think what Mr. Bradford's point is, that it's one thing to have a set of procedures and a piece of equipment, and it's another thing to be trained on how to use them.
MR. MARTIN:
It's my conclusion, based on the training that we understand them to have received and our review of their training, that thei-r fundamental training and level of knowledge should have been sufficient for them to recognize that they were in a very adverse set of circumstances~
moreso than an unusual trip; and that,
- coupled with the instructional guidance they had and the procedure they were using, which was the procedure on the loss of reactor coolant or reactor coolant system pressure, they should have recove~ed i
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instructions that were available.
They should have recovered from the transient as they got into it.
COMMISSIONER GILINSKY:
Could I just ask youy are members of the team that conducted this investigation -- have any of them held operator's licenses?
MR. MARTIN:
Running down through the list, yes, yes.,
MR. STELLO:
How many of you have operator's licenses I or have ever had one?
Raise your hands.
(A show of hands.)
MR. STELLO:
Two.
MR. _tv'f..ARTIN:
And myself.
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,1 53 COMM.ISSI ONER GI LINSKY:.~Three.
MR. MARTIN:
The other point that we were able to ascertain is that during the early phase of the incident, during the period of decreasing reactor coolant system pressure, again, because of the conviction that the reactor coolant system was solid or had adequate inventory, again because of the pressurizer level, the core flood tanks were isolated during the period when it was approaching the injection point for the core flood tanks.
And we then re-isolated, clearly, at some point later on, because those were used later during depressurization.
The only reason we bring those up is, again, there's a second example of an action taken that had a.leak out of the EMOV or at some other point, got worse, and had there been rapid depressurization those core flood tanks would have been isolated for a long period of time.
Okay.
Once the management staff arrived and set up the emergency team that directed both operational and off~site activities.
And Al, of course, will address the major portion 1
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But with regard to the
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command team was set up to provide advice to the station 1,
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they reached, with four specific exceptions that we would 3
comment on.
4 One is the disbelief by them of the high system, process system of in-core temperatures.
This information was 61 being presented to them in about the 8:00 a.m. to 9:00 a.m.
I 71 time frame.
What we have not been able to ascertain at this 8 II point -- let me back up a little.
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We have talked to the ll I'
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'I*he plant manager recalls being given a few data points with largely diverse numbers, whereas our report, which shows a total listin~
of all the data available, would show overwhelming evidence of something else.
We were not able to ascertain how mouch data in fact 24 I!
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COMMISSIONER GI LINSKY:
When was *the period of major core damage.
What I am getting at here is, suppose the plant managers or NRC knew at 8:00 a.m. that temperatures in excess of 2,000 degrees were being read, which I gather was the cas~, or between 8:00 a.m. and 9:00 a.m.
Could actions have been taken at that point to mitigate the extent of core damage?
MR. MARTIN:
My understanding is that the major extent of core damage occurred in this 6:30 to 7:30 time frame,'
two and a half hours.
These were, I think, readings taken after what I believe is the assessment for the major period of core aamage.
MR. STELLO:
The answer is yes.
Any time you would have put on more water and got more water in the core, you would have mitigated the amount of damage that the core had.
(At 10:45 a.m., Commissioner Bradford left the room.)
COMMISSIONER GILINSKY:
I'd say it depends on what time we're talking about, doesn't it?
MR. STELLO:
It doesn't depend on that at all.
The accident was finally terminated by putting more water through the core.
Had that been done at any time earlier than that, it would have caused less damage to occur.
COMMISSIONER GILINSKY:
The question is how much 25 I less.
In other words, when was the period of major damage?
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Almost in proportion to the amount of time earlier you did it.
COMMISSIONER J..BEARNE:
Could you give a between?
CHAifilv.lA.N HENDRIE:
There were:, a couple of bad
- patches, 1
one in about the third hour, as I recall, after the tripping.
The HPI had been throttled back, way back, continuing to lose water out the relief valve.
The coolant pumps were tripped.
MR. STELLO:
Between 6:00 and 7:00 a.m.
CHAifilvJ.ll...N HENDRIE:
Yeah, between 6:00 and 7:00 a.m.,
because the first strong indication of fission products loose in the system turned up about what, 6:15, 6:20, something like that, 6:30.
And then it see~s to me, then after that there was a period in which they increased the pressure by running the HPis a little harder and the pressurizer and so on, and 15 that may have probably inhibited void formation to some degree 16 in the core and may have improved the cooling situation.
17 But there was a later period which went on for four 18 I or five hours when they were trying to get depressurized down I
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into the residual heat removal system pressure rating range.
I 20 I And I would think that would be also a time when you would I
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(At 10: 46 a.m., Commissioner Bradford returned to the 23 Jj room.)
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T ere were severa perio so core Ace-Feoeral Reoorters, Inc.'.!
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I 2 I COMMISSIONER GILINSKY:
So what you' re saying is, II,I 3 i\\
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took place?
MR. STELLO:
Surely.
Don 1 t pin me down to time.
If it had been taken earlier, it would have(r~duced damage in proportion to how much earlier it was taken.
Clearly, if it were taken at 6:30 you may have been at a point where the fission product inventory conceivably could have been limited to perhaps failed pins.
COWHSSIONER GILINSKY:
Right.
But the information was available at 6:30.
COMMISSIONER AHEARNE:
When was the first contact?
CHAIRMAN HENDRIE:
Well, the core thermocouples went over and began to print their off-scale marks.
It must have been when, around 6:00 o'clock?
MR.
MARTIN:
There were some computer entries --
MR. STELLO:
If you were getting core damage, you would have had to have the in-core thermocouples indicating high temperature..,
COMMISSIONER GILINSKY:
And these were observed at roughly that time?
MR. ~~~RTIN:
No.
These were on the plant computer I
rote 10 7
8 58 in the 8:00 to 9:00 time frame, was when a more systematic evaluation of going and culling out data from the plant computer, taking data from the buffer, converting it to temperatures outside of the range.
That's the more systematic.!
We have been able to find computer data points in which there were high values listed, but we don't know that there was a systematic effect attempt on the staff to program them up.
COJ,,TJ1ISSIONER GILINSKY:
Were any amounts measured of ii 9 :1 those?
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COMMISSIONER AHEARNE:
I think the question is when was the earliest time that a high temperature was actually caJ-led up?
13 COMMISSIONER GI LINSKY:
I.' m sorry, I understood you 1,, I to be saying --
15 16 17 I
- ,a 11 i 9 I MR. STELLO:
Let me try it again.
The in-core thermocouples are on the computer, and they go off-scale at about 700 degrees.
There were times subsequent to that that people saw very high temperatures that were measured directly in the cable spread.
COMMISSIONER GILINSKY:
You were saying that was 8:00 to 9:00 0 1 clock.
MR. STELLO:
The point I'm trying to make is, once the thermocouples have gone off-scale on the computer is an indication of a superheat condition, at which time you could have decided, I didn't have enough water in the core, and began
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COJv'.i!USSIONER GILINSKY:
Sure, but did anyone notice those values going off scale?
COJv'lMISSIONER AHEARNE:
That's my question.
When was the earliest time that they actually measured or noticed the high temperature?
MR. STELLO:
That's the trick.
CO~ll~ISSIONER GILINSKY:
I was simply picking up on his remark that they knew about high temperatures between 8:00 and 9:00 o'clock, and I was asking you if they acted on that information, could they have significantly reduced the amount of ultimate core damage.
And you're saying yes.
Yes.
You know when they first bbserve_d:
the thermocouples going off-scale on the computer, the first time they called it up.
MR. P.ARTIN:
The first entry that we have down, based on the data records, there was one singular one and I know we have it in the report and I don't recall the tim~.
But:
the first time at which there was a repeated entry was starting; at 6:55 a.m. on one in-core location, 657720.
C01'-:1MISSIONER GILINSKY:
This is off the computer?
22 ri MR. Ml>-.RTIN:
This is off the computer.
Ii 23 Ii COMMISSIONER.A.BEARNE:
Did that mean it had been I!
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In this case they had been called up.
rote 12 60 This is a case in which, if it goes off scale, it rings a 2 Ii question mark; then as soon as it comes back on scale, it ii 3 11 prints out the current value as it comes back on scale.
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Let me pin this down.
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you saying at 6:55 someone on the staff was aware COM.MISSIONER AHEARNE:
No, he didn 1 t say that.
MR.. MARTIN:
No, sir, I wasn 1 t saying that.
I was saying at 6:55 a.rn. the computer was starting to alarm and print out data.
If an individual during that 6:55 --
COMMISSIONER GILINSKY:
When was the first ti.me someone in that contrG*l-room knew about the high temperatures?
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It was approximately 8:00 a.m.
COMMISSIONER GILINSKY:
When was the first time they knew about temperatures over 2,000 degrees?
MR. MARTIN:
In that same time frame.
It I s in the 8:00 to 9:00.
We 1 re basing it on interviews.
We don 1 t have hard data.
This is an interview, and it was in the 8:00 to 9:00 a.m. time track that that information was accumulated off of the computer, because when you look at temperatures that high, you cannot read them off of the computer.
You must,
go down and make measurements.
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COMMISSIONER GILINSKY:
No, T understand that.
MR. MARTIN:
So _it's in the 8:00 to 9:00 time frame.
COM.MISSIONER GILINSKY:
You mentioned about not being clear whether this information was available to Met Ed management.
MR. MARTIN:
To the emergency director in his capacity of directing the activities.
His interviews and our discussions with him would indicate that the information as it came in to him was that there were a few temperatures registering in these values, and there was a range from zero to 2600 degrees, and only a few temperatures.
The data we have would suggest that a lot more data was taken.
COMNIS,SIONER GILINSKY:
You donlt seem to make any-thing in the report, at least I don't find it, about their not reporting the separation to the NRC.
And I don't see that listed as a potential noncompliance.
17,i Do you not regard it as falling in that category?
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I 18 I MR. MARTIN:
No, sir, we did not view the reporta-1 19 il bili ty of this incident and its several factors as a
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reportable item of noncompliance, because they have submitted
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COMMISSIONER GILINSKY:
Yes.
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~ II 1s I 62 MR. STELLO:
It's an interesting point. I'll think about it.
I don't think we're prepared to give you an answer.
And now that you've raised the question, there are several others that might fall into that out of the hydrogen -- I'll have to give it some more thought.
I don't know if there's a particular license require-ment that would fit or not.
But I want to give it some more thought.
The answer is I don't know.
COMMISSIONER AHEARNE:
I'll try once more to get an answer to the question, which is, as far as you can tell, when was the first time that they knew of the high temperature.
I mean, I understand your point that the computer itself has this!
information.
But that's an automatic reaction, not a called-up.
I i
Can you tell when it was first called up?
1 MR. MARTIN:
It's addressed in here.
But in any event, at the point at which information was sufficiently collected together that it was felt that it was important enough to try to get it to the emergency director was in the 8:00 to 9:00 o'clock time frame.
That would be the period of time in which those people handling that data felt that it was,
important to pass that information through.
COMlHSSIONER AHEARNE:
Do I interpret correctly that, as opposed to some of the other items that you mentioned, where the operators did not follow procedures, there's no specific procedure to be followed if the temperatures go off-scale or
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ii II 63 if a large number of temperature readings go off the computer scale, or if there are indications of very high temperatures?
.MR. MARTIN:
That's correct, sir, because for all the analyses that were performed as part of their training and!
development of procedures, this sequence of events was not one that occurred.
So therefore they have no operating procedures to address when things go off scale.
that they would go off scale.
There was no anticipation COYiMISSIONER AHEARNE:
So that nothing -- in other words, once it got into the situation where the thermocouples were reading that high, they were going into areas that they had nothing spelled out to follow?
.MR.. Ml'-_RTIN:
That's correc't.
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25 I 64 I will summarize the other two points.
Pressurizer behavior was misunderstood by the emergency team :as we11 as the emergency staff. It really addresses the same issue as was addressed previously on the mind set.
Also, the behavior of the core flood tanks during that period of approximately later on in the day when they attempted to pressurize and concluded from the core flood tank discharge behavior that the core was covered because of the way in which the tanks behaved, also indicated a misunderstanding on their part as to, one, the piping configuration, and two, whether or not the core flood tank behavior would in fact be indicative of core coverage.
It might be, but it does not assure it; and they felt assured that it was.
COMMISSIONER KENNEDY:
You said a misunderstanding on their part of the piping-configuration.
i I
MR. MARTIN:
There are two aspects.
It turns out tha ti there are loop similar to the loop seal which has become a topib of discussion relative to the pressurizer.
~here are also loop seals in the lines from the core flood tanks.
SQ, from looking at the behavior of the core flood tank purely from a static behavior, not considering even the deynamic aspects of adding water to a hot core, but even from a static behavior it would be difficult to assure core coverage just by virtue of the loop seals.
The The people in the emergency croup at that point did
pv2 2
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5 65 not in ::fact realize that that piping had been run with loop seals.
So, that was a contributing factor, but not the only factor.
Okay.
CHAIRMAN HENDRIE:
Let me ask with regard to the i tE;=,.111 before this last one.
When the alarm printer shows an item 6
like one of those in-core thermocouples, what does it do?
Doesi 7
8 9
10 11 12 13 14 15 16 17 it print it out?
Just ding a bell or light a light?
MR. MARTIN:
It just prints it out.
CHAIR.IvlAN HENDRIE:
It just prints it out?
MR. MARTIN:
It prints it out.
As I recall the sequence -- and I will be glad to have someone from my team correct me if I am mi~taken -- but as I recall, when an in-core'thermocouple goes off scale, it prints the _question mark to show that it's bad.
And then when it comes back on scale, it prints when it is cycled through and sought again by the computer sequencing system.
It prints the returning number as it comes back m scale.
COMMISSIONER AHEARNE:
But if it's still a question 19 mark, it's still off scale?
20 i MR. MARTIN:
It would not print again.
It would just 21 print as it goes off scale.
It would print the question marks 22 and, I think, gives a bad term next to it, just prints "Bad" 23 or "Such and such bad."
24 COMMISSIONER AHEARNE:
Now, how much of a time lag at i
Ace-Federal Reporters, Inc. I 25 that point was the printer?
66 MR. MARTIN:
The times 2
were~in the 6:55 to 7:00 range.
we're J.ooking at, some of thos7 If the operator pressed "Alarm I I
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pressers," we think he might have done that about 6:48.
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9 would not be much time lag in any case if he had not.
Up until about 6:48 we think the computer was running something like an hour and a half behind real time.
COMMISSIONER KENNEDY:
Is that a normal state for 10 I that computer?
I il I MR. MARTIN:
No, sir, that was because oi5 the high 12 number of alarms coming in and just the time it takes for that 13 typewriter to print across each line with the alarms coming in.
14 That time lag would grow with time as the number of alarms 15 increased.
16 CHAIRMAN HENDRIE:
Apparently, the first printer 17 I
i rn indication that the in-core was beginning to go was 30 and a few minutes.
The first entry I find in the event description l
is:
I 19 I No. 149 at 31 minutes.
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COMMISSIONER GILINSKY:
Does that mean that the I
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was, in effect, not contemplated for use in accidents dealing 22 II with accidents, where you would have a lot of alarms and where 23 I it would fall well behind real time?
24 MR. MARTIN:
I really don't know what the design basis Ace-Federal Reporters, Inc. \\
25 was :for bringing in that particular design of computer.
I know
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101 11 12 13 14 15 16 68 CO~.MISSIONER GILINSKY:
Just so that it doesn't get in the way.
CHAIRl~~N HENDRIE:
That it doesn't get in the way.
MR. STELLO:
For the sake of adding even more discus-sion to this item, I will take the risk to note that a particu-lar parameter that should have been a parameter that the staff was B.ware of at the plant and *the operators should have been following would have been the system temperature, and you're focusing only on the in-cores.
If you lo.ok at Item 208, the system temperature, at about that time it starts to go up, and 14 minutes thereafter it's off scale, and that's at 6:00 a.m. 1 T,o.answer your question, again, they clearly --
CO.V.lMISISONER AHEARNE:
They had -an indication.
MR. STELLO:
They should have been watching that one, because they were trying to decide whether they had natural 17 circulation.
That's how you do decide, by looking at the inlet 18 and outlet temperatures.
19 COMMISSIONER AHEARNE:
Even at an earlier time, a 20 point that the chairman mande, event 149.
I 21 MR. MARTIN:
I looked at that.
However, I think there 22 is not another one; I think that was a singluar one.
I don't 23 think it was bad, really, but it was a singular one.
It was not 24 the start of a large number in closed sequence.
There was some' Ace-Federal Reporters, Inc.
25 time frame before a large number of such printouts started to
pv4 67 the licensee now is considering dhanging over to a high-speed.
2 printer type.system to increase the rate at which alarms can 3 I be printed out.
4 I I also know that the operators did not make use -- I 5
believe I mentioned this back in the May briefing -- that the 6
- operators did not r..outinely make use of the computer as a real-
. 7 time working device because of the fact that once you got into s
a period of high alarms -- that might be any trip barring an acci-1 9
dent, but any trip -- the printer immediately starts running 10 11 behind.
So they don't use it as a real-time device.
COMMISSIONER AHEARNE:
I gather also then that the NRcl 12 never required it to be a high-speed printer.
13 14 15 16 COMMISSIONER GILINSKY:
I was about to ask that.
COMMISSIONER AHEARNE:
Is that correct?
MR. MARTIN:
I believe that's correct.
COMMISSIONER' '.GLLINSKY:
We not only didn't require 17 a high-speed printer, but presumably didn't expect them to us.e 18 this to deal with accidents.
19 MR. MARTIN:
We did not expect.
I don't think that 20 we would address that.
I 21 CHAIRMAN HENDRIE:
This is part of the stuff provided 22 to the plant which is outside the limits of the safety review 23 generally.
One could only look at this to make sure that it 24 didn't have an interaction possibility electrically back in the,
Ace-Federal Reporters, Inc.
25 safety circuit.
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25 71 aware of the pressure spike. This was about 2.: 00 in the after-noon.
They were aware that a pressure spike had occurred.
They did not interpret this in terms of hydrogen or hydrogen release or hydrogen:<letonation.
It was coupled simulataneous with the opening of an EMOV.
The shift supervisor who was on duty coupled that to the opening of the EMOV and steam release.. into the building, not another cause.
And there was, in fact, a further confuion added, because roughly 30 seconds after that, two electrical buses short-circuited and tripped out.
That -- those trips were prob a 1
probably caused because of the equipment wetted down by the I
building spr~y operation.' Tha~ introduced the belief that mayb~~-.
i it was the electrical problem that triggered it.
But nonetheless, there was a recognition of a pressureJ I
spike having occurred, by the operating staff. It was *not I
I I
related to hydrogen.
The reporting, once it was related to the:
I possibility of hydrogen spike, was reported, we think, promptly,!
once they determined that condition.
COMMISSIONER GILINSKY:
Let me pursue that point.
First of all, the question of whether it should have been reported to the NRC in the first place when they became aware of it.
But, as I understand it -- and please correct me if I am wrong --
toward the end of the second day they did relate it to hydrogen and they did think in terms ;of a hydrogen explosion
pv6 69 occur.
But that was a singular printout.
2 The next area*--
3 4
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9 10 1 l 12 13 14 15 MR. STELLO:
Maybe I ought to add a personal note.
M experience in the operations center led me to believe that they really didn't believe, even later in the morning and later in the afternoon, they just didn't believe the temperatures, they just didn't believe them, they didn't believe that they were real.
They knew about them.
I know they knew about them later because we talked an awful lot about them.
And I don't think they believed them.
COMMISSIONER AHEARNE:
Are the thermocouples tradi-tionally that is, thermocouples in reactor~ traditionally instrl.!LIIlents that do malfunction' on this large scale?
MR. STELLO:
I am not an expert in the area, but I asked a question, and the answer that I got was that thermo-16 couples generally, if they're reading, they're correct.
When 17 they fail, they usually fail off scale.
One way or the other.
18 COMMISSIONER AHEARNE:
So, the disbelief wasn't 19 related to a conclusion.
There is a set of instruments that 20 usually fail.
It was more disbelief that the phenomenon that 21 the instruments were predicting couldn't happen.
22 MR. STELLO:
Well, the answer that I got in one 23 instance is, "I believe my core is covered; and if my core is 24 covered, I wouldn I t be getting these,kinds of temperatures."
Ace-Federal Reporters, Inc.
25 That's the kind of logic I ha-ve been getting.
Can you shed any
pv7 2
70 logic on the way the operators'did *in fact feel?
Did they real really have a disbelief that these in-core thermocouples and th
')
I system thermocouples were correct?
Can you add anything more 4
5 6
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9 10 11 12 13 14 to that?
MR. MARTIN:
No, I really can't add any more to the general sense that you just gave.
Ther~ was a convic~ion that the core was covered; therefore the system temperatures cannot be real.
Therefore, that served as the basis for discounting temperaturs.
COMMISSIONER AHEARNE:
But they were not in any way, as far as you can tell, based upon any kind of experience that l
the thermocouples were instruments whose readings they shouldn 1J pay any attention to?
MR. MARTIN:
What they used to further support that 15 rationalization was that the thermocouples are not safety grade, 16 and the system RTDs, the readings were being taken on them out-17 side of the ranges of their calibration.
And that was sup-18 portive rationalization to their basic conclusion, which was 19 1 that the core was covered, therefore I can't have those tempera-I 20 I tures.
I 21 Okay, I think we have discussed previously about the 22 pressure spike in the building not having been pursued.
We did 23 look into that further because of questions that were raised 24 during the last briefing.
And we do believe that the interpre-Ace-Federal Reporters, Inc.
25 tation given by the staff at the time, the operating staff were
pv9 5
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11 12 72 in the containment.
Yet, the NRC was not infiormed until the morning of the following day.
MR. MARTIN:
I believe that's right.
It was late in*
the evening that they had come to that c-onclusion.
And that would be late on the evening, I think, of the 30th, and promptly.
MR. STELLO:
The 29th, on Thursday.
COM..MISSIONER GILINSKY:
And the NRC was informed on the morning of the 30th.
MR. MARTIN:
That's right.
COMMISSIONER GILINSKY:
I must say I don't regard thatj as promptly.
COMMISSIONER A.HEARNE:
Considering we had people 13 there, it was certainly not due to an absence of phone communi-14 cation.
15 MR.. MARTIN:
In our view of that, we did not conclude 16 a fault or an improper behavior in that area as compared to the I.
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25 I requirements you have introduced.
COMMISSIONER GILINSKY:
Isn't there some general requirement that information which is of high safety importance ought to be communicated promptly to the NRC?
You keep refer-ring to "requirements."
This doesn't specifically violate some specific requirement.
MR. STELLO:
We're going to take a real hard look and make sure that we look with a vi)ew in mind of wondering whether '
there is or there should be, maybe if there isn't there ought to
pvl0 2
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9 73 be.
But all I can ask is that _you give us some time to go back and think about it.
None of us sitting here at this table went through the thinking process of immediate notification for issues such I
as the two that we already discussed -- the in-,core temoeratures;
~
i and hydrogen pressure.
We'll go back, we'll look.
COMMISSIONER AHEARNE:
At least from your understand-ing as you know now, you don't know of anything -- if I turn that around the other way, would it be, fair to say that as far I
I 10 as I&E practice ;says, that the licensees are not given the feel-[
11 ing that they must report anything that is out of the ordinary 12 with respect to safety issues?
13 MR. STELLO:
Right *now, licensees are clearly on 14 notice to let us know anything out of the ordinary, far less 15 significant than these issues, but with respect to the specif~c I
I 16 question.can an enforcement action be taken in light of the factl 17 that they didn't tell us in a more general way rn COMMISSIONER AHEARNE:
I recognize the final sta9e of i,;,
i the enforcement action.
I was just actually backing up earlier. i 20 Is there anything that would have led the licensees in general, 21 from, say, I&E's approach to licensees or NRR's approach to 22 licensees, that if there is something that could be potentially 23 serious in a safety matter, to immediately let us know, even if 24 I there isn't some specific requirement that -- or some specific Ace-Federal Reporters, Inc. 1 2sj requirement linked to it?
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l l 12 74 MR. STELLO:
I think, as a general matter lice.nsees do that.
But what we 1 re dealing with here is not licensees, it's individuals that have some cases dif information which may or may not have been "corrmmnicated" to that i-ndividual who has that responsibility and that sensitivity.
I think licensees, people who are in charge of that responsibility, have that sensitivity, whether it exists within the organization where all people would have that sensitivity is another matter.
I think when the people on site are made aware of these at management levels, they did make us aware of it.
COMMISSIONER AHEARNE:
In general, in the review of 13 the operators and management people, what kind of a sense did 14 you come away with as far as did they feel it was solely their 15 responsibility to handle this accident?
16 MR. MARTIN:
Yes.
And I think I will probably touch 17 on that on the very next topic I was going into.
18 MR. BICKWIT:
Before you go, could I just refer you lC I to a section of the regulations, 2121.
It talks about notifica-20 I tion with respect to the facts, and it says initial notification I
I 21 \\ required by this paragraph shall be made wi thi.n two days fol-22 ilowing receipt of the information.
I am not familiar with the I
23 /history of this regulation, on how to interpret it, but that i
24 I would seem to approximate a requirement of the regulations.
Ace-Federal Reporters, Inc. I 25 COMMISSIONER AHEARNE:
Of course, that regulation,
pvl2 4
5 75 like, I think, most of *them, are really geared-more to a situa-tion that is under control, rather than the stages of an acci-dent.
MR. MOSELEY:
Could I contribute a little bit, or try to.
I think that historically in IE and the relationships with 6' licensees, it's been that regulations are not specific on 7
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, I I
l O I individual detailed events related to a larger event.
I think our intention -- because this is the largest accident that.has ever occurred, we really haven't been faced with this kind of a~
issue in the past.
I think it is something new that needs to 11 I 12 be looked at, and we need to come up with something.
But, by and large, our approach -- and, I think, the licensee's approach:
13
-- has been that the reg~lations addres~ themselves to the 14 event itself and it doesn't get down to the nitty-gritty, to 15 individual things; and in all other events that I am aware of 16 this has teken care of all of it because the event is over.
17 COMMISSIONER AHEARNE:
At least my understanding is 18 that the regulations didn't have embedded in them the concept 191 that there.was going-to be a crises management over some I
10 I extended period of time.
I 2, I 22 I I 11 MR. MOSELEY:
That ' s true.
COMMISSIONER GILINSKY:
Let me say it seems to me, to I
i 23\\iraise the question whether the management had this information 24 \\ would seem to suggest that if they did that it would have been Ace eral Reporters, Inc. I 25 transmitted to us; if in fact-the management didn't have this
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76 information -- the plant management -- it seems to me it makes it far worse:
it suggests that the plant is out of control.
So, I regard that as a mitigating. factor.
You refer somewhere else here in connection with procedures regarding some of them as improperly adopted, that it's indicative of a serious breakdown in licensee knowledge level of the facility.
That's the sort of thing that seems to me to be at issue here.
MR. STELLO:
That is at issue, and it is a potential item of noncompliance.
CHAIRMAN HENDRIE:
Pray go on with speed.
MR. MARTIN:
With the off-site interfaces, I think I would like to, perh~ps recognizing that Item 1 is the licensee corporate staff Could you put the next slide on, please.
(Slide.)
Remembering the licensee corporate staff, Babcock &
Wilcox,and the NRC as interfaces in which there was an attempt
'9 I 1 i!for active interfaces in those areas.
Burns & Roe was the 20 I 21 22 1 architect engineer.
There was functionally no intBrface.
They offered whatever help, and no help was requested from them.
In terms of the licensee corporate staff, the diffi-23 cul ty there appeared to be a rapid transmission of up-i:-to-da t_e cur-!
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25 Ian issue that was questioned before.
I And I think this addresses I
In an accident of this I
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77 sort, the responsibility is resting with the emergency team that's present on site.
None of them, of the analyzed acci-dents, really brought into focus the possibility of such a protracted event taking place where one would hope to establish an ongoing contact on a minute-to-minute basis with support organizations, but that the accident would rapidly take you virtually into a recovery phase in a very-short time frame.
So, the mechanism of contacting was basically by tele-i I phone, and it suffered from time delays.
The usage of the available lines over which long-distance phone calls could be made, along with the various other contacts that could be rquired, resulted in a condition where Babcock & Wilcox could 1
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not be contacted directly from the site because there were not I
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phones available at that.point that could make the long-distance; i
calls, so they had to make a local call to a local B&W employee at his home off-site, and he would relay messages to B&W.
COMJ.IUSSIONER AHEARNE:
How many lines were there going 18 off-site?
I 19!
MR. MARTIN:
I don't know the answer to that, not in I
20 I terms of the specific number of lines.
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Could I then now ask the question I just asked a minute ago?
In the context --
I recognize when it first started that all of these previous training, they didn't have this understanding of procedures or whatever you want to call it, that they should bring in support organizations.
I also gather that would also extend to give the NRC a lot of detail.
But this began to extend over a lengthy period of time.
As you went through with the management and the operators, what would you say was their view of what their role ought to be with respect to us, say, during that day?
Was it still, here's a peripheral function that we have to try,:
when we have time, to eiamine?
MR. :tv'iARTIN:
I think basically, in terms of the data, they were very promptly informing us of data for the purpose of letting both the region and the headquarters staff know what the condition of the plant was and what data was available.
When it came to issues of plant, what the licensee plans were, there was a distinct time shift between actions taken within the inner circle of the emergency corrmand team, that organizational structure, and the time at which those things would be passed on to the NRC for people other than 23 the people on site.
Even for the people on site, there was a 24
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79 The time lag did not exist with regard to data, as far as we can tell.
As far as we have been able to establish, we do not believe the presence of the NRC or interfaces that occurred between NRC headquarters or the region and the operating staff really affected the course of any actions or decisions reached by the licensee during the course of handling!
that accident.
There may have been issues in which he considered one or more additional aspects or topics, but we can find nothing in which there was a major change in the course of events.
COMMISSIONER AHEARNE:
Do I gather, then, also by that time lag that yori're talking about, there wasn't 0 either-an attempt to incorporate us into that small c'ore planning team, nor he belief that there should be?
MR. MARTIN:
I believe that would be a correct appraisal.
If I may, I also believe that we found no evidence '
of any attempt specifically to forbid.
COMMISSIONER AHEARNE:
I understand that.
But it still sounds like they were continuing this sort of two-day reporting requirement philosophy, that it was their job to handle this and they would let us know.
I'm not necessarily criticizing them.
I'm just trying to make it clear.
COM.MISSIONER KENNEDY:
Is there a job to handle?
I want to be sure we understand.
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11 80 CO~.J.USSIONER AHEARNE:
As I said, I'm not trying to criticize.
I'm just trying to make clear.
CO.MMISSIONER KENNEDY:
I'm sure we understand what we're saying.
Noncompliance is something different.
COMMISSIONER AHEARNE:
I'm not implying anything.
The second question:
You said that there was never any time lag in the data transmission?
MR. MARTIN:
Very little. If I said never any, I don't mean it that way.
COMMISSIONER AHEARNE:
That will bring me back to those high temperature readings, what you said was transmitted to the management team between 8:00 or 9:00 o'clock.
MR. MARTIN:
Some amount of it, an undetermined amount of the data.
COMMISSIONER AHEARNE:
Were those high temperature readings transmitted to us?
MR. MARTIN:
No, sir, they were not.
COMMISSIONER AHEARNE:
I didn't think so.
MR. MARTIN:
What I meant about the data when I said that, I obviously was not clear enough.
I meant plant parameter system data.
Now, that accumulation of data was, if you will, taken, accumulated outside of the normal instrumentation displays, and fed towards the emergency command center, and then not utilized.
So it was not in the normal availability of knowledge available in the control room, and it was that
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'I Ii 81 general knowledge I was referring to in terms of being available to the Commission.
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I think that generally characterizes the 4 I interfaces.
ii There were time delays to some extent.
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With regard to the closed emergency feedwater valves, we were not able to ascertain exactly who, how or why they were closed prior to the start of the accident.
I think you're all aware of the apparent conflicting information well, it's not conflicting information.
The surveillance procedure lends itself to the possibility that they could have been left close after surveillance.
T~e operator who i
I said he was associated with that procedure said he specifically I I
remembers opening those valves and they were closed at the start of the accident.
We cannot tie those tog*ether and make a definitive statement as to who closed them or how they were closed.!
COM.MISSIONER JI.HEARNE:
Is there a written record of the reopening cif the valve after the maintenance?
MR. MARTIN:
No, sir.
That's one of the issues that's addressed in the report, in the sense that those aspects of the surveillance procedures are not retained.
Another aspect in the report is that they are also not reviewed, not necessarily independently, and there is no
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COMMISSIONER J\\...HEARNE:
Do we have any requirements, general procedural requirements either that it be reviewed or that they be retained?
.MR.. MARTIN:
Yes, sir.
And that's addressed in the report as items which are also under consideration.
COM.MISSIONER AHEARNE:
So we do have requirements.
MR. MARTIN:
And they have it in their program.
Okay.
The second item was the emergency director did leave the site at about 2:00 o'clock in the afternoon.
He had deferred his leaving of the site until later, having objected to being ordered to leave the site earlier in the day to brief the lieutenant governor.
He did leave the site. It is our view that he took all the prudent steps that one would expect to take precautions, to let people know where he was, to put a person in charge.
charge.
It was not that there was no one in:
COMMISSIONER AHEARNE:
Who ordered him to leave the site?
MR. Jl.lARTIN:
The vice president for generation ordered him to appear at the lieutenant governor's office to brief him.
We felt that he took prudent steps in preparation to do so.
CO~J1ISSIONER AHEARNE:
Now, is that type of an action, the action of emergency director and the station
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83 manager leaving, something that we would approve, disapprove, comment on?
MR. MARTIN:
I think we might comment on it. It would not be something -- we were not aware that he was off the site.
I could find no evidence that any of our staff were aware that he was away from the site at the time.
He did maintain contact with the site.
He did return to the site.
We cannot -- to evaluate the impact of his not leaving might have been what the effect of his leaving might:
have been on the course of the accident might have been, we don't know.
COMMISSIQNER KENNEDY:
What you do say is remaining on site might have altered subsequent actions that might have been taken, this in regard to the pressure spike.
MR. MARTIN:
Yes, sir.
I was going to get to that, that aspect.
The other aspect, that as soon as he and* the vice president for generation returned to their respective stations, one to the site and one to the observation center, it was shortly after the briefing on the status of the plant that followed their return that the decision to repressurize the plant and start a reactor coolant pump occurred.
- Now, would that have occurred two and a half hours earlier if they were not gone from the site would be conjectural.
There were certainly conditions changing during that
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9 10 I 11 12 13 14 15 16 17 84 two and a half hours,* but not dramatfcally or drastically.
So again, they.left the site and took precautions, and then returned when the new course of action was chartered.
It might have occurred earlier.
We don't know how to answer that.
.The. third item was, there was concern during the last briefing on the availability --
COV.!MISSIONER KENNEDY:
One other question in that regard.
Was there anyone else who, in your view, might have taken care of the problem in terms of the organization as it stood at that time?
COMM.ISSIONER AHEARNE:
I guess you're not really sure.
CHAIRl".lAN HENDRIE:
You might have to ask the lieutenant governor.
.My understanding was, though, it was a fairly urgent request from the state capitol to report.
MR..MARTIN:
I think the feeling was that there was i8 a request from the lieutenant governor to the licensee to get 19 I some straight first-hand information, and it was the I
20 I vice president's view that the best man to do that would be 21 the emergency director on the site.
22 Finally, with regard to the plant computer records 23 and accuracy, I would like to just readdress the point that I 24 made at the last briefing on this.
We do not feel, based on Ace-Federal Reporters, Inc.
25 a rather extensive look into.the records, that any records
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were purposefully thrown away, lost or destroyed, to hinder our investigation.
We really don't think we were hindered at all.
There is one mass of data missing for about an hour and a half, and we really think, although we cannot prove it, but our strong inclination is to believe that an operator hit a button on that computer which essentially clears the memory to get everything up to date, which is a very appropriate action for him to take.
COMMISSIONER AHEARNE:
About 6:40 or something like that?
MR. MARTIN:
This is the 6:40-6:50 time frame.
We believe this occurred, but we cannot find the operator and we cannot make sure that this aid indeed occur.
COMMISSIONER.AHEARNE:.I assume this means that you asked all the operators who were there?
MR.. MARTIN:
They don't remember or they don't remember whether they did it. It would not have stuck out in their minds as anything significant.
They just would have punched a button to bring it up to date and gone back to work.
COMMISSIONER KENNEDY:
But that would have been a normal thing for them to have done?
MR. MARTIN:
Normal.
There's no question of 24 propriety.
Ace-Fe-::ieral Reporters, Inc. i 25 I 1
I think that concludes my presentation.
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,86 COl'-'.IMISSIONER GILINSKY:
Can I ask you, i*s there some particular reason why names were left out of this report?
MR. MARTIN:
I would prefer to have management address that.
MR. MOSELEY:
Yes, sir. It has been our practice in the past, to protect the privacy of people, to exclude their names from this type of investfgation.
CO¥~1ISSIONER AHEARNE:
You say that there are no records that you believe were deliberately lost?
MR. IvT.ARTIN:
Computer records.
I'm not implying by that I think there are others that were intentionally lost.
But those are the ones that I was addressing at the time, computer records.
COMMISSIONER.A.HEARNE:
So for example, surveillance records we were just talking about?
MR. MARTIN:
Those were intentionally thrown away, which is, you know, improper, and we've addressed it in the report.
But I don't think it was done -- that's the way of 19 I handling it.
I
'1 20 ii CO1'--1MISSIONER.A.HEARNE:
In other words, it's not a I
21 i selected set of surveillance records.
22 Ii MR. :MARTIN:
They do it with them all.
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CO.MMISSIONER.A.HEAP.NE:
Standard procedures.
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That was a practice long before the t',a>-Feoeral Reoorters, Inc. Ji 25 i investigation started.
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87 COMMISSIONER AHEARNE:
And.it sort of caused some problems with the NRC audit type of procedure.
MR. MARTIN:
Yes, sir.
COJl.'ISSIONER GILINSKY:
Could you say something about the previous loss of feedwater event, which was not reported to the NRC, what significance you attach to that?
MR. MARTIN:
The significance we attach to that, sir CO~ITSSIONER GILINSKY:
And in that case, the emergency feedwater came on.
MR. MARTIN:
It functioned.
And in the review of thpt event, the licensee -- this was, I believe, November 3rd, 1978.
I presume yqu're addressing the one that we had talked about before.
COMMISSIONER GILTNSKY:
Yes.
MR. Jl.1ARTIN:
During *that transient, what we are stating is that the licensee basically did not review the plant response closely enough to have identified that fact, if they had moved the plant into a degraded mode of operation.
1 The degraded mode of operation means that they had moved into an action statement, they are not meeting the LCO, limiting condition for operation.
Now, in such an event they should report to the ii 24 i[
NRC that, as a result of this transient, some aspect of the w.c:£-Feoeral RePOrters, Inc, ti,,
25 11 safety-related system did not meet in accordance with the II ii 11 I!
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design.
And that's what we're addressing~ that we feel that they did not analyze it carefully enough and identify that in fact the plant did not completely conform to its design.
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COlvJl.HSSIONER GILINSKY:
So they should have reported MR. Jvl..ARTIN:
That's right.
COMMISSIONER GI LINSKY:
To what extent were -they 8
9 10 11 awane i of the Davis-Besse event?
MR. MARTIN:
lve pursued that with training.
COMMISSIONER GILINSKY:
About a year earlier.
MR. MARTIN:
Both the Davis-Besse and the Rancho Seco 12
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events, neither of those had been incorporated into the trainin~
program for the operators or staff.
Now, we did track that there was a distribution under operating events, operating 15 16 I
experience.
MR. MOSELEY:
Current events.
MR. MARTIN:
That there is a distribution made by rn the NRC and that some of that had gone out to the licensee.
19 i But that basic information had not filtered down and been ii incorporated into the training program.
I COMMISSIONER GILINSKY:
B&W didn't notify the licensee 22 d about that event?
" !i 23 11 MA MR.
RTIN:
I' No, sir.
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Could that have something to do with the fact that the valves were made by different j:
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25 89 manufacturers in the two cases?
MR. ¥.lA.RTIN:
I'm trying to remember.
In one of those events, it was concluded that, because df a feedwater transient that had occurred at T.MI and that B&W had given advice and commented on a TMI-based event, that B&W did not feel it necessary to comment on a similar type of feedwater event at another facility, since they had already provided comments on a TMI feedwater event.
CO:MMISSIONER GILINSKY:
On the ~MI-2 event?
MR. lf.lA.RTIN:
It was the TMI-1 or 2.
It's in here under the discussion of whether or not the Rancho Seco and Davis-Besse event were covered by training.
And I j~st do not remember it off the top of my head.
CO.MM:ISSIONER GILINSKY:
Was any of,'th~ in,formation you obtained in this connection -- well, from any of the interviewees conflict with testimony that was later given to the Presidential Commission?
MR. l1ARTIN:
I am not MR. STELLO:
We have an investigation that is going to start to look into that question.
Until it's complete, I'd ra-L~er not comment.
COMMISSIONER.,!:1..HEARNE:
As far as the Davis-Besse thing* goes, for one more question on it:
Neither the operators nor the management when you talked to them, I guess, did not
- seem aware, at least aware ih detail, of that event?
rote 13 90 MR.. MARTIN:
That's correct, they were not.
2 COMMISSIONER AHEA.RNE:
So *that when you say that we 2 *,
had provided in the current events bulletin that comes out, 4
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But as far as what happened to it and incorporation into the understanding, you couldn't find that out.
MR. MARTIN:
No.
We started to pursue that late in the investigation, and frankly, we terminated once we estab-lished that it had not in fact gotten down to the training level.
That we were able to ascertain, that it had not reached that.
aspects?
MR. GIBSON:
Shall I begin with the radiological COMMISSIONER GILINSKY:
Sieze the moment.
CHAIRMANIENDRIE:
Yes.
Just a second before you do.
Let me make a comment on the schedule.
The Commission's schedule had showed us hearing a briefing on the results of the investigation, the briefing we're now having, and then moving on to hear presentations and discussion of the proposed fiscal year 'Bl budget for Commission offices.
The latter discussion I propose to defer until tomorrow morning.
So that for those of you that have attended this morning interested not in the briefing on TMI, but only in the forthcoming discussion on the Commission office budgets,j I
I I
mte 14 91 I apologize.
If there is any rush for the rear door, I'll 2
understand.
I 2 1i With that announcement, why, plunge ahead on the ji
'I 4 :1 radiological side with dispatch.
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,:>,ci;-Feoernl Reporters, Inc. l\\1 25 I i1 MR. GIBSON:
Okay, thank you.
The first slide, please.
(Slide.)
I'll begin it with a discussion of pre-accident conditions.
I will be as brief as possible so as not to repeat unnecessarily information given during my June briefing.;
The total radiation protection and chemistry staff consisted of 39 tndividuals, four of whom were on site on the morning of the 28th prior to the accident.
COM1'1ISSIONER AHEAR..3/4E:
i Is that the normal complement?!
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MR. GIBSON:
Yes, sir.
Seven emergency drills were conducted by the licensee!
I in 1978. to evaluate the adequacy of emergency response capa-bili ty.
One of these drills was observed by an NRC inspector.
Critiques were held following each drill to discuss results and assign action to collect problems identified.
Most of the identified problems were corrected to the extent that they did not recur following the March 28th accident.
Two exceptions wel'.i'e: An environmental iodine survey instrument was taken from the plant to Goldsboro for use Wilithou~
further verifying that it was operational.
Once at Goldsboro,
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141 1s I 16 Ii it was determined.not to operate properl:Y**
A similar problem had occurred during the drill.
And another example is that during the previous drill the need for operations personnel to re-review criteria for declaration of site emergencies was identified and, as we will discuss later today, there was apparently still some misunderstanding on the part of operators as to when the site emergency should have been declared.
In addition to drills, which obviously do have some training advantage, formal training is provided to instruct each member of the plant staff in his emergency duties.
(At 11:40 a.m., Commissioner Bradford left the room.)'
MR. GIBSON:
Such training had been provided at TMI with, ag~in, a few exceptions.
One exception was that the off-site monitoring team members had not been trained in the use of instruments to be used for airborne environmental radioactive iodine samples.
And this training caused techni-17 1[
1 1i cians to be unsure of their abilities in using the instrumen-
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of the instruments' response to Xenon.
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~8 19 20 21 22 23 24 25 93 Another example, weil, to move on, routine training for radiation chemistry technicians on the plant staff was not up to date in that training required by the technical specification, a retraining program as required by the technical specification had not been implemented to maintain their job proficiency to comment on radiation protection equipment and~supplies, althbugh -equipment and su_pplie s were adequate to.s.upport normal plant operations.*
Shortages occurred following the accident.
Inventories can be summarized as follows:
less than half of the portable radiation monitoring instruments were operable, although delay in maintenance and calibration of such instruments --
COMMISSIONER KENNEDY:
Excuse me, wh,en were we first aware of that?
MR. GIBSON:
We were first aware of it, we were first aware of it during the investigation.
This was disclosed upon review of records of maintenance and calibration on survey instruments.
COMMISSIONER KENNEDY:
What normal provision do we have for reviewing the status of such equipment on normal inspection routines?
MR. GIBSON:
We do review this during normal inspections.
COMMISSIONER KENNEDY:
When was it last reviewed
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10 1 1 12 13 14 15 16 17 18 19 20 21 22 23 24 25 94 before this investigation?
MR. GIBSON:
It was reviewed, okay, I donJt remember the date.
The regulatory requirements regarding minimum inventories are very general.
COMMISSIONER AHEARNEt Are you saying that with half of them not working that would have met the regulatory requirements?
MR. GIBSON:
Yes, sir.
COMMISSIONER KENNEDY:
It would?
MR. GIBSON:
Yes.
COMMISSIONER AHEARNEg Is it an overexaggeration to say that the regulatory requirement allows inventory for normal operations but does not handle accidents?
MR. GIBSON:
The regulatory requirement, which is i.n effect a commitment in the FSAR on the part of *the I
licensee, in this case as it was generally worded, lacked specificity.
I don't remember the eiact words, but it was something to the effect that we/11 have instruments of the various types and in sufficient quantities to support operations or something to that effect, and this is not uncommon.
COMMISSIONER KENNEDY:
If 50 percent of the total inventory is inoperable, is that then still meeting the regulatory requirement, in your judgment?
COMMISSIONER GILINSKY:
What is the regulatory
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10 J l 12 13 14 15 16, 17 18 19 20 21 22 23 24 25 requirement?
Is it a certain number.of meters?
COMMISSIONER AHEARNEz No.
MR. GIBSON:
No, sir, it was a general requirement.
95 CHAIRMAN HENDRIE:
If the inventory is two meters and one of them's down, and only one's working, why, I'd say that doesn't meet the requirements.
In fact the whole inventory doesn't~
On the other hand if it" s 1 000 meters and 500 of them work, why that seems to me an excessive requirement.
So it's the numbers rather than having a batch of them down, although if you buy a batch of instrument, why, you generally expect to keep a little better than 50 percent availa.bility in a good _shop.
l.R. GIBSOH:
Some problems have b_ee.n observed in this area in the past.
An outage on Unit 1 had just been completed during which the instruments received heavier than normal use.
Consequently, the number out of service was higher than normal, 50 self-contained breathing devices and 175 full face respirators were available.
The full-face respirators were equipped only with particulate filters and thus were not effective for iodine protection.
The number of self-contained breathing devices was later shown to be not su.ff icient to su_pport entries into the auxiliary building.
This problem was compounded by lack of
5283 07 04 kap -
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'I 6 17 18 19 20 21 22 23 24 25 96 facilities to quickly recharge the gas bottles on the self-contained breathing devices4 There were not enough high range pocket dosimeters available to provide one for each individual or grot{_p of individuals entering the auxiliary building.
COMMISSION ER AHEARNE:
But I think it--' s correct that that lack doesnJt violate any of our regulations.
MR. GIBSON:
That is a true statement, and another cormnent on radiation survey instrumentation, there was no instrument available on-sits which would read an exposure rate greater than 1000 rem, or 1000 roentgens per hour.
And following the accident, levels in excess of this value were present, which is perhaps a Lessons Learned for all utilities. This is typical, __
COMM i SS'IONER AHEARNE:
I gue -?s it" s al so a Lessons Learned for us.
MR. GIBSON:
Yes, I would think so.
Regarding emergency equipment, four en~ironmental monitoring kits were in place providing supplies and equipment for use by an emergency monitoring team.
The iodine monitoring instrument in one of these kits was known to be out of service, and the iodine instrument in a second kit was found to be out of service at the time it was first attempted to be used, but only one kit was required by the emergency plan implementing procedure.
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10 J I 12 13 14 15 1 6 17 18 19 20 21 22 23 24 25 97 To comment.on the routine environmental monitoring program that was in place prior to the accident, the program was in place as required by technical specifications.
Environmental air samplers were operating at eight off-site locations and TLDs were in place at 20 off-site locations.
CHAIRMAN HENDRIE:
Let.J's move along, please, or we/re never going to get out of here.
I.J'd like to cover this radiological thing in the next 20 minutes and then have about 15 minutes to deal with the potential non-compliance items, and close the briefing in the neighborhood of 12:30, please.
Let us move rapidly along.
COMMISSIONER AHEARNE:
Let me ask, quickly, a question.
These are -
in talking about pre-accident conditions, shortly before the ace iden t,. the l i cen s ~e had had a review of a physics program by. a consultant, and that consultant.J"s report was extremely critical of the licensees health physics program, the training, and the accuracy of the procedures, et cetera.
A lot of the things, in fact, that it calls out, you might say were precursors of the problems that you just found.
We went through and watched one of their drills.
Did we reach similar conclusions?
Had we come away with a similar criticism?
MR. GIBSON:
I must say, I have not reviewed the
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JO 11 12 1 3 14 15 16 17 18 19 20 21 22 23 24 25 98 inspection report of that drill.
I have reviewed the audit report, and I will say that I believe the findings of our investigation support many of the i terns in the audit report, but I really cannot answer your first question.
COMMISSIONER AHEARNE:
So we hadn't, as far as you know, reached any conclusions prior to the accident about the weakness of the procedures, the weakness of the training?
We had no t, a s far a s I know
- Just a word on rad waste systems.
A reactor building sump was aligned to pump the auxiliary building sump tank only about 800 gallons of surge capacity remained in this tank.
Auxiliary and fuel handling ventilation systems we~e operating normally, discharging through high I
efficency tilters and charcoal filters.
Next slide, please.
(Slide.)
MR. GIBSON:
l"d like to talk about initial emergency response and detection and classification of the accident.
The Emergency Director was responsible for classifying the situation as an emergency in accordance with conditions in Table I of the emergency plan, by taking accidents in accordance with emergency pl an implementing procedures and his own best judgment.
The first condition in Table l that appeared to
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10 JI 12 13 14 15 16 17 18 19 20 21 22 23 24 25 99 have been met was specified -as Criterion C for site emergency.
Conditions for Criterion C were met by 4:15 a.m. on the morning of March 28th.
This site emergency criterion action level states., *11 that si.te emergency should be declared-
upon loss of primary coolant pressure coincident with high reactor building pressure and/or high reactor building sump levelo By 4:15 a.m., reactor coolant system pressure had dropped f rorn 2435 ps ig at the time of the trip to-a pproxirna tely 1275 psig.
COMMISSIONER GILINSKY:
Does a si.te involve off-site complications?
MR. GIBSON:
Yes, sir. This pressure was below the reactor coolant. low pressure trip set point of 1940 psi.
the se.t point for emergency cooling -initiation at 1600 psig.
At 4:15 a pressure rise of about 1.4 psig inside the re~ctor building was detected.
The shift supervisor was aware of the drop of reactor coolant pressure and increased reactor building pressure.
Initially, he evaluated these conditions in relation to the emergency plan and indicated that they were not indicative of an emergency, since primary coolant system pressure had stabilized and there was no increased radiation levels either in or being released from the facility.
(Commissioner Bradford entered the room at 11:50.)
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.22 23 24 25 J 00 COMMISSIONER AHEARNE:
Are the criteria to declare a site emergency su£ficiently fuzzy that it was really a judgment call of his, or did it say, if A, B, happens you should --
MR. GIBSON:
The criterion is just as I stated it.
COMMISSIONER AHEARNE:
So your conclusion is he should have declared it.
MR. GIBSON:
Niy conclusion is.it should have been declared; however, I think it is a more complex issue than attributing it to operator error.
Terms such as loss of reactor coolant pressure and high reactor building pressure were not defined.
COMMISSIONER AHEARNE:
There are no numbers a5sociated with it?
MR. GIBSON:
No numbers, so part of the fault was with lack of specificity in procedures and also lack of understanding on the part of the operators as Bob previously discussed, as to what was really happening in the plant.
COMMISSIONER AHEARNE:
So i t.,s more than hindsight that one can conclude that it should have been?
MR. GIBSON:
That-' s true.
COMMISSIONER GILINSKY:
Are you saying that they considered the question and decided not to call a site emergency?
MR. GIBSON:
Yes, sir.
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JO J l 12 13 14 15 16 17 18 19 20 21 22 23 24 25 101 COMMISSIONER GILINSKY:
At 4: 1.5?
MR. GIBSON:
Yes, sir.
They considered the question and at that time reactor coolant pressure had stabilized somewhat, although it was low on the order of 1200 psi, but they felt they had control of reactor coolant pressure and the shift supervisor said that he did not consider that to be a loss of pressure, even though the pressure was low.
He didn't consider it ~o be a loss of pressure.
So he did not declare a site emergency at that time~
Now, at 4:30 he became aware of an additional criterion, and that was a high alarm on the reactor building sump, which, because he still had no indication of any release off-site, he still did not declare a site emergency.
'COMMISSIONER GILINSKY:
Did you detect any.
reluctance on their part to call a site emergency because this might lead to unfavorable publicity or whatever?
MR. GIBSON:
That was not explicitly stated by people --
COMMISSIONER GILINSKY:
Did you ask?
MR. GIBSON:
Yes, sir, I believe the investigators did ask that question.
Perhaps Mr. Donaldson could answer that.
MR. DONALDSON:
It was not implicitly stated.
We asked the questions within the bounds of the criteria as
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15 102 they were stated and tried to get their perceptions about what they felt these various levels meant.
My own "evaluation would be that I don"t think that they did perceive the meaning of those levels.
I would think in my own mind that there was some reluctance on their part because of the magnitude of the response that would have been required to that event.
MR. GIBSON:
A second criterion COMMISSIONER AHEARNE:
In the training, do they get trained at all on that aspect of it, how to interpret those criterion?
MR. GIBSON_:
I"m not aware of specific training, no, sir.
Not on attaching numbers or more specificity to those general terms.
COMMISSIONER AHEARNE~
Do we in our review of.
16
- _operators or supervisors ~o thro~gh any of that, as a normal 17 event?
l 8 MR. GIBSON:
I'm not aware -- I'm not familiar 19 with operator training, not that I'm aware of.
20 A second criterion for the declaration of site 21 emergency was met at 6:35 when an alert alarm set point was 22 reached on the reactor building dome monitor.
This 23 apparently went unnoticed.
24 25 COMMISSIONER KENNEDY:
Went unnoticed?
MR. GIBSON, Yes, sir.
6283.07 11 kap 2
3 103 COMMISSIONER KENNEDY:
How was.the data recorded~
and where?
And thus, how did it go unnoticed?
MR. GIBSON:
Okay.
We don.I' t know for c er ta in that 4
the alarm o_ccurred~ the trace occurred on a strip chart 5
recorder and at 6:35 a.m. the trace passed through the alarm 6
set point for that monitor, presumably the alarm occurred at 7
the S'et point.
8 COMMISSIONER AHEARNE:
So as.far as what you 9
actually know_, are sure ha ppsned, is that the trace went 10 through there.
l I MR. GIBSON:
That*,.s correct.
l2 CHAIRMAN HENDRIE:
This would have been an 13 enunciator light, presumably on the panel and by that time, 14 15
!6 why the whole enunciator panel must have looked like a Christmas tree.
COMMLSS IONER GI LINSKY:
In the summary of the 17 report, it states that subsequent to 4:15, there were 18 several radiation monitor alarms indicative of an emergency 19 situation but no emergency was declared.
What times are you 20 talking about?
Are you referring to these events at 6:30 or 21 something earlier?
22 MR. GIBSON:
These were area radiation monitors in 23 the auxiliary building and in the reactor building that 24 would have been indicative of increasing radiation levels in 25 the plant.
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lO 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 104 COMMISSIONER GILINSKY:
At about what time?
MR. GIBSON:
After 6:QO oJclock.
The site emergency was declared at 6:55 after the pv reactor coolant pump was restarted and distributing fission products thoughout the plant, causing a rapid increase on radiation monitors throughout the plant.
The criteria for declaring a general emergency is also stated in Table 1 of the site emergency plan, and the general emergency Criterion B requires declaration of a general emergency when a whole body dose in excess of CCH{MISSIONE:R GILINSKY:
Would they not have started that pump at that time?
MR. GIBSON:
Should they not have started the pump?
I can't answer that.
COMMIS-SI*ONER AHEARN~:
Vic, what do you know?
MR. STELLO:
I don't have any reason ~o believe that besed on the information that they had available to them, there ~as reason to not start the pump.
Clearly at some point the thing to do was to start the pump and terminate the transiente So I don't attach anything of significance to the attempt at restarting j_t.
It was moving in a direction in which it was eventually going to go.
MR. GIBSON:
The initial dose calculation projected a dose that was in excess of five rem, as we will
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16 17 18 19 20 21 22 23 24 25 105 discuss later, but a general emergency was not declared at the time because that proje:ction was believed to be unrealistically high.
COMMISSIONER KENNEDY:
Why was that?
What was the rationale for that?
MR. GIBSON:
That-'s the Goldsboro dose of 40 r per hour, that we discussed in the last briefing.
The general emergency Criterion A, which requires declaration of a general emergency when a high alarm occurs on the monitor, was met at 7:20.
COMMISSIONER AHEARNE:
In other words, a high alarm isn*'t the earlier one that you're talking about.
MR. GIBSON:
'11he earlier one was an alert ala.mt.
This is a high alarm and it was based on this high alarm that a general emergency was declared at 7:24.
Upon declaration of a general emergency, the emergency organization was activated and it was the organiztion, was assembled initially as shown in the emergency plan implementing the procedures.
The shift supervisor on duty at the time assumed the position of emergency director in the Unit 2 control room until he was relieved by the station manager at 7:o 5.
A radation chemistry technician was intially placed in charge of the emergency control station at the health phyics control point in the Unit I auxiliary
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10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 106 building.
He was later relieved by a foreman at 7:1.5 and the supervisor of radiation protection at 7:35.
COMMISSIONER AHEARNE:
The site emergency, if they declared a site emergency, did +/-hey have to notify us?
MR. GIBSON:
Yes, sir4 In fact, the prescribed actions are very di+/-ferent for a site general emergency.
COMMISSIONER AHEARNE:
But on the ~ite, they woul'ti have had to notify.us?
MRe GIBSON:
Yes, sir, and they did.
COMMISSIONER AHEARNE:
I will leave this briefing with this impression~ though, and I want to make sure you don't agree with it.
They had several indications during that period of time, even though there was this general fuzziness about specific numbers, between that 4:15 and 6t55~ there still hadn't been an accumulation of information that would not have b.een unreasonable for them to have declared that.
In fact, it would have been quite reasonable.
MR. GIBSON:
I would agree with that.
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l0 J l 12 13 14 15 16 17 18 19 20 21 22 23 24 25 107 (Slide.)
We'll discuss pathways of radioactive effluents briefly.
Following the turbine trip, about 8000 gallons of reactor coolant were pumped from the reactor building sump into the auxiliary.
COMMISSIONER AHEARNE:
I'm sorry, Vic.
Is that an example of a procedure that they should have followed?
Declaring the site emergency earlier, is that an example of a procEdure they should have followed?
MR. STELLO:
We have listed an item of non-compliance potentially.
COMMISSIONER AHEAP.NE:
But in your list of things that you had when you started, if they had followed the procedures, is that one of the ones -- in other words, if they ha,d declared that they would have gotten NRC pea ple
'called earlier, is that one of the t~ings you were thinking?
MR. STELLO:
That would have made -- prevented the accident?
COMMISSIONER AHEARNE:
Or made it less serious.
MR. STELLO:
No c MR. GIBSON:
So 8000 ga.llons of water were pumped to the auxiliary building,_overfilling the auxiliary building-' s sump tank and spi.ll ing into the sump.
COMMISSIONER GILINSKY:
Are you saying that there would not have been any significant difference in the course
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10 11 12 13 14 i5 16 17 18 19 20 21 22 23 24 25 108 of this accident if site emergency had been declared at 4: 15?
MR o STELLO:
I was asked the quest ion *-- the question was whether, had they followed that procedure, did I have that in mind when I made the statement that the a cc iden t was preventable 0 The answer to that quest ion is, no, I did not have that in mind.
COMMISSIONER AHEARNE:
The accident, the serious consequences, would have been ---
MR. STELLO:
I do not believe 0that had we been notified earlier, that the severity of the accident would have been much different than it was.
The mind-set of the people that were making the decisions, I don't believe, would have been changed by our interaction.
When we did try to interact ind we did try to persuade ~hem of a different point of view, we were ~nsuccessful in doing that, in my view.
So I don/t believe an earlier notification would have changed that mind-set.
COMMISSIONER GILINSKY:
Let/s see, that also calls into play their management at an earlier point, when they called the site emergency, doesn't it?
MR. STELLO:
I believe their management was being called in independent of the declaration of site emergency anyway.
- GI BS ON :
They we re ca 11 e d
- I t was a f t e r 4 : l 5 *
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MR. STELLO:
It was prior to declaring site emergency.
The need for additionaL assistance was a decision, as I understand it, that was made independent of reaching a decision on site emergency.
CHAIRMAN HENDRIE:
Forward.
MR. GIBSON:
Okay.
Following fuel damage, concentration -or radioactivity in reactor coolant increased by several orders of magnitude, and a flow of this highly contaminated reactor coolant was maintained through the makeup of the purification system for several days following the accident.
This flow was the principal pathway by which radioactivity was transferred from the damaged reactor core to the auxiliary and fuel handling buildings and ultimately to the enviro~ment.
COMMISSIONER GILINSKY:
So you-'re confirming your earlie~ view that it was not the flow from the containment sump?
MR. GIBSON:
That is correct.
COMMISSIONER AHEARNE:
So lack of containment ventilation wasn-'t *-
MR. GIBSON:
That--l's correct.
COMMISSIONER GILINSKY:
Was there some way to seal off the makeup and purification system?
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10 l 1 12 13 14 15 16 17 18 19 20 21 22 23 24 25 l I 0 MR. GIBSON:
In fact, that flow was automatically isolated on an i~olation signal, but it was manually opened up again in order to maintain inventory control over the reactor coolant system at the control pressurizer level.
COMMISSIONER GILINSKY:
So as a practical matter, there was not way to prevent that flow?
MR. GIBSON:
That~s true.
To control the primary system?
MR. GIBSON:
That*"s correct.
And so the flow was maintained through the auxiliary and fuel handling buildings.
There was really not an alternative to that.
Okay.
Gas is evolving from the reactor coolant inside, makeup the purification system, were collected in the ~aste gas system.
Small leaks in the waste gas system.
which had been of little radiological consequence prior to the accident became importantant after the accident because of the high concentration of radioactivity.
It is believed that these leaks were the principal pathway by which radioactivity entered the atmosphere in the auxiliary and fuel handling buildings and was ultimately discharged to the environment from ventilation.
COMMISSIONER AHEARNE:
These leaks were within tech specs?
MR. GIBSON:
The reactor coolant leakage,
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10 l l 12 13 14 15 16 17 18 l9 20 21 22 23 24 25 1 1 1 unidentified reactor coolant leakage as Bob mentioned earlier, was outside of tech specs&
But the tech spec does not address a leak rate for gases, and we believe it was a gaseous leakage that did contribute mostly to the environmental release.
Now some gases did evolve from liquids spilled onto the floor, but it does not appear that this was the major pathwayo COMMISSIONER.AHEARNE:
But then are you saying that even if they had identified what had been the cause of the leak, as you now say, the calculations show they were outside of tech specs.
Even if they had identified that and fixed it and put it back within tech specs, you still expected that the leakage would have occurred?
MR. GIBSON:
That1 s.true.
To discuss briefly monitoring of airborne effluents, airborne radioactivity monitors are installed ln ventilation exhaust systems and in the station vent.
These were o+/-f scale, as we discussed in June, because of the high radiation levels in the vicinity of the detectors.
The response of these monitors provided little useful information during the period of this investigation.
However, the samplets associated with these monitors were used to coilect iodine and particulate samples, which were then analyzed in laboratories for a before and after assessment of what had been released from
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9 10 J l 12 13 14 15 16 17 18 19 20 21 22 23 24 25 112 the facility.
Rega~ding quantification of what was released from the facility, the licens~e did not quantify noble gas releases until after the period of our investigation.
However, because of the high degree of interest in this subject, we did put information in the report regarding the licensee-"s assessment of a quantity of radioactivity released.
We did.not independently ~alculate the quantity of radioactivity released, but we did review the methodology used by the licensee and found it to be sound.
And we did compare the noble gas releases to a preliminary assessment Which had been made by the NRC staff with that, to be consistent.
COMMISSIONER AHEARNE:
And ttierefore also consi~tent with that a8 hoc task force that looked at the measurements?
MR. GIBSON:
That is correct.
I think I should say more on that point.
We took the noble gas source term identified by the licensee, plugged it into a formula in 10 CFR 20 to determine compliance with JO CFR 20, and found that the 10 CFR 20 release concentration, annual average concentration limit, was excEeded by a factor of 11.
Now this would normally imply --- the MPC in part 20 is generally regarded as a concentration -- if someone were present in that concentration continuously for seven
>283 08 07 mgc -
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10 J I 12 13 14 15 16 17 18 19 20 21 22 23 24 25 l 13 days a wsek, 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> a day, it would produce 500 millirems per year.
Now when we came up with a factor of 11, I think a reasonable question is, does that mean a person would have received Jl times 500 millirems a year.
The answer to that question is, no, it does not mean that.
It doesnJt mean that because of conservatism in the dose models used to derive 10 CFR 20 MPC values and becau£e of conservatism in the atmospheric dispersion factor which we used to determine compliance with part 20 and because no one leaves at the
, site boundary 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> a days seven days a week, without the protection of any shielding.
And when corrections are made for those conservatisms to obtain a more realistic dose, our number s_eems consistent with what the ad hoc committee produced.
And also I would add that the ~d hoc committee's estimate is based on ~ctual doses measured by TLDs and does not take into account in its determination of doses to individuals a calculation using an atmospheric dispersion factor.
Now, our calculation is based on taking the TLD
_ result, applying an atmospheric dispersion factor to get a source term, and then applying another atmospheric dispersion factor to project out to an individual.
The combination of the two atmospheric dispersion factors introduces some additional uncertainty.
So the bottom line
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Next slide, please.
(Slide.)
I'd like to talk briefly about in-plant radiation protection.
It was in this area that many of the problems we identified occurred.
Radiation levels increased drama tica.lly.inside the auxili 2.ry building and the fuel handling building fo.llowing the accident.
Exposure rates increased by several orders of magnitude from a few millirems per hour to hundreds of rems per hour.
Operations of valve circuit breakers and inspection of systems for leakage and performance surveys were made.
Positive control was not always exercised over these inputs.
Although many of the individuals entering the auxiliary building were briefed by ei t.her the Radiation Protection Supervisor or the Supervisor of Radiation Protection and Chemistry, not all were.
Entries were made into high airborne radioactivity areas and high whole body exposure rate areas, and in one instance, a survey estimate was not used.
Two individuals who entered the auxiliary building received a whole body dose of radiation in excess.
Others were contaminated and received excess doses.
High range pocket dosimeters could not be located and were not worn.
Protective clothing was
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COMMISSIONER AHEARNE:
A.11 of those are the kinds of things that at least the management ~urvey or the heal th-physics survey indicated would have been expected.
MR. GIBSON:
Yes, I think so.
Air sampling was not performed in the auxiliary building where workers were exposed during essentially the entire period of the investigation, and appropriate respiratory protector devices were not always worn.
And records of radiation exposures received by workers do not appear to be accurate.
COMMISSIONER AHEARNE:
So the conclusion after I listen to that would be that we really are uncertain as to the occupational exposure.
MR. GIBSON:
There is some uncertainty on that, yes, sir.
We believe that we have investigated the cases where the greatest risk for b:igh expo.sure exi'sted, but we do not wish to imply that we have identified all of them.
We have encouraged the licensee to go back and do further evaluations, and he is doing so.
COMr!iI SS I ONER AHEARNE:
Have you al so alerted or warned the individuals that they might have been exposed to substantially higher radiation levels than they were aware of?
MR. GIBSON:
The licensee has done that.
COMMISSIONER AHEARNE:
YouJre sure?
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I would not say it has been done in every case.
I know it has been done in some cases.
COMMISSIONER AHEARNE:
Shouldn-'t it be done?
MR. GIBSONg Certainly it should be done once it's determined that an individual did receive more than what he's previously been led to believe.
In practice, such determinations usually irrvolve discussions with the individual to determine which area heJs been in.
COMMISSIONER AHEARNE:
I would think we--' d have some kind of responsibility to at 1-east make sure the licensee has alerted its employees *that they may have been exp::,sed to substantially higher levels of radiation.
CHAIRMAN HENDRIE:
Since we don't know that he hasn..,t, why don't we pass on.
COMMISSIONER AHEARNE:
I feel very uncomfortable about feeling that while we--'ve got it really pinned down --
they don't have it pinned down.
CHAIRMAN HENDRIE:
I-' 11 comment that I was on the site a couple of times, and I have had the exposure record forwarded to me.
I--'ve got my little sheet that says, you know, dosimeter shows so much.
I would expect that he has, in fact, been notified.
COMMISSIONER AHEARNE:
Joe, I think we a.11 have.
Howard, what I--'m really worried about is the first couple of days when I don't think that formal system was in place.
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Let me help maybe to verify.
Did they have to go back and do whole body counts on a great number of those individuals to see if there was trouble in those areas?
MR. GIBSON:
Yes, sir.
The whole body count would indicate that there had been an uptake of radioactivity inhaled.
MR. STELLO:
Other than that, they had their TLDs on.
MRo GIBSON:
The problem is that not all of the TLD results were entered into the record, and that that/s a questionable area is what I think the Commissioner is con sider i ng $
Regarding what caused these practices, I would_
like to first say that we have conc1uded that the.training of'the radiat{on protection and chemistry staff and actions of some workers did not reflec~ comprehension of problems such as the n~ed to know exactly when iridividuals entered and returned from areas of radiation hazards, the need to measure and document air~orne radioactivity to which workers were exposed, and the nBed to perform detailed surveys of personnel contamination.
We questioned workers regarding their training, almost to a man.
The radiation protection and chemistry sta.ff was dissatisfied with the amount of training they had
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10 J 1 12 13 14 15 16 17 18 19 20 21 22 23 24 25 J 1 8 b_een provided, and response to.technical questions indicated that they did need more technical instruction.
I could go on and list other examplese In addition to training, we felt that the management control over exposures during the accident was not all that it should have beeno Examples of that would be that positive access control was not established to prevent entry of unprepared individuals into hazardous areas.
An effective method was not implemented to a.ssure that individuals entering hazardous radiological environments were fully briefed as to the hazard, and the degree of urgency with which the task was.to be performed.
Equipment such as high range pocket dosimeters andf survey meters were not controlled to assure that each individual entering the highxadiation ~rea was provided with, appropriate instrumentation.
Individuals that became contaminated were not properly surveyed and decontaminated to ensure that their dose would be minimized, and planning of those tasks which presented considerable potential for radiation does, such as reactor coolant sampling, was not reviewed by knowledgeable members of management to ensure that reasonable precautions were to be taken.
CHAIRMAN HENDRIE:
Of course, I think it-'s also fair to notice that some of the entries in the first three days, four days, were also being made under circumstances
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119 when there was concern over substantially higher doses for everybody, not only in the *plant but on site within the plant limit.
And so, I think these things ought to be duly noted ang taken account of in emergency preparations.
But*-
MR. GIBSON:
I think youJre right.
CHAIRMAN HENDRIE:
I think we_ought to recognize that.some of these actions which sound couched in these phrases as thought, my goodne_ss, how could they have done a dumb thing like that?
And the answer was, if IJd been there and running it, why I'd have done the same thing on the basis that it's better to take those shots and deal with the plant condition and avoid much higher if possible avoid much higher -- doses going in and out of the plant.
COMMISSIONER KENNEDY:
This may be a reflection of the comment which Norm Mosely made at the outset of this presentation, that if one takes only what is being specifically presented here as the total, factual situation, you wiil have an unbalanced picture.
In fact, all that~s being presented here is the bad side.
COMMISSIONER AHEARNE:
Both of those are correct.
The only caveat I'd have is that there was a study done for the licensee of their health-physics program prior to the accident in the absence of this kind of severe crisis situation.
And that pointed out just these kinds of
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poor training~- unc.ontrolled access, unthoughtabout allowing 9f peopl~ to go into areas without monitors, so that even in a much less pressured situation, all those weaknesses were there.
So I'd certainly agree with you, Joe, that in a pressure situation you make some balanced judgements.
But I think the underlying fact is that that whole system wasn-'t very well developed.
CHAIRMAN HENDRIE:
It-'s clear from the consultants-' report that it could stand substantial upgrading.
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.e 14 15 16 17 18 19 2.0 21 22 23 24 25 121 COMMISSIONER GILINSKY: Let me ask_this:
How did it compare with th_e situation in other reactors?
MR. GIBSOi~: I would say that the amount of training provided to radiation chemistry people at th.is rea~tor is not that atyp.ical of what I would expect to see elsewhere.
Perhaps a little below par, but not that much di ff ere nt *
.I th.ink th.e proble.ms in this case became more apparent because of the challenge to the program.
COMMISSI01~ER AHt:ARNE: Are you suggesting that if we went out 2nd either reviewed other plant health physics operations ourselves or hired someone to go out and review it, that they would similarly find these kinds of weaknesses?
MR. GIBSON: They miqht.
But bear in mind that when we reviewed a program during noi~al operations, the regulatory requirements may, in fact, be m~t because the program has not been challenged to the extent that this one was.
COMMISSIONER AHEARNE: 3ut I"m asking a different question.
1/m asking if we were to do a review of other plants such as Met Ed had done for their plant, either ourselves doing it or hiring someone else to do it, would you expect that other plants would similarly find a large set of iv ea k n e s s es ?
MR. GIBSON: Yes, sir, I would.
COMMISSIONER AHEARNE.: Then I guess that we ought to
,6283. 09. 2 esh 2
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MR. GIBSON: The_problem is the reviews that we normally do are to determinE compliance with regulatory requirements.
And_the review that was done by the consultant in this case was like a management eYaluation.
His findings were not necessarily supported by regulatory requirements and, in fact, were not always supported by detailed, factual bases with the opinion of the evaluator.
Cq/v\\MISSIONER GILINSKY.: It ra_ises.a quest.ion as to Whether requirements are what they should be.
COMMISSIONER AHEARNE.: R.ight.
COMMISSIONER BRA'.JFOR'.J: Is that an NRC evaluator or a licensee evaluator?
MR. GIBSON: No,- it was private.
CO MM LSSIONER AHEARNE: M...et Ed had hired someone.
MR. GIBSON: Let me move on with the environmental.
Next slide, please.
(Slide.)
The initial off-site dose calculation was made by a nuclear engineer in +/-he unit 2 control room.
It was completed at about 7.:10 a.m.
The result was reported and calculated to be 40 ~ per hour.
The calculations were not retaind and the basis of this result is not known.
Within the next few minutes, the 40 R per hour --
COMMISSIONER GILINSKY: 40 R?
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123 MR. GIBSON= ~er hour-That was declared at COMMISSIONER AHEARNE: This was the calculation.
COMMISSJDNER GILINSKY: When was that don.e?
MR. GIBSON: This was the.first calculation done, which was completed at 7:DO a.m. on the 28th. Within the next fev; minutes, apparent!)' an error \\J/as noted in this calculation and it was reYised down to 10 R per hour.
The licensee did not believe this number.
They thought it was unrealistically high.
The basis of the formula being used was an assumed containment leak rate at the maximum allowable value.
And
~ressure and containment was 1-l/2 PSIG, as opposed to 56 PSIG.
. And based on that. the people in the control room assumed the numbers were unrealist.ically high.
Now we have ~ince determined that the number was high because the engineer'misread the monitor. the dome monitor meter.
And he read a number to be 30,0DO millirem per hour.
That was actually ~00 miliirem per hour on the dome monitor meter.
Now after the site emergency had been declared, environmental monitoring teams were assembled and were sent out to make measurements.
The first measurement didn~t come back until 7:48 a.m.
This was a measurement --
COMMISSIONER GILINSKY: Let me ask you this.
If the licensee had a responsibility to give advice to the local
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.11 12 13 1'4 15 16 17 18 19 20 21 22 23 24 25 124 government on whether or not an evacuation was appropriate MR. GIBSON: Yes, sir.
COMlvtISSIOi~ER GILINSKY: Shouldn_;t he hav.e gone in there?
CHAIRMAN HENDRIE: Absolutely.
MR. GIBSON-: And the licensee d.id discuss the 10 R per hour number with the state.
COMMISSIONER GILINSKY: They did discuss it with them.
MR. GIBSON: Yes, sir. lt was about 7.!-22, as I recallv somewhere in that time-frame.
And the first survey result came back about 7J48.
This was a result that was measured on the island between the plant and Goldsboro and it showed less than one millirem.
And around 8.!30, the first result from Goldboro came in,. which also showed less than one millirem.
The fact is the projection was in error.
COMMISSIONER AHEARNE.: I gu.ess you.,.re also saying that the methods that they h.ad ava.ilable for doing the calculations weren t that well developed.
iv\\R. GIBSOi~: That.,.s correct.
They wer.e developed in the procedure that they were based on the dome monitor reading because the sta+/-f monitor by this time had gone off scale.
And they -
the procedure did not take into account COMMISSIONER BRADFORD.: D-1d the procedure start with the stack monitor, then, assuming it was on scale?
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125 MR. GIBSON.: The procedure, yes, sir, do.es.
COMMISSIONER BRADFDRD: Well, let-'s see -
MR. GIBSON: The procedure calls for summing the CO/v;MISSIONER BRADFORD: What you-'re saying is. though, with enough radiation going.up the stack to drive that meter o_ff scale, you could still g.et a reading o.f less than a millirem less than a mile away, which I should think would make the stack monitor readin~ just about usele~s.
COMMISSI01'JER AHEARNE.: For a.ccess
- COMMISSIONER BRADFORD: That.,s correct.
But even if it were a very mild event, indeed --
MR. GIBSON.: A mil.l.irem a mile away is reaJ.ly a v.?ry high number.
COl*.W.ISSl'ONER BRADFORD: But even on site, it was still.under a millirem.
- v1R. GIBSON
- Yes, sir, even a rnillirem due to effluence on site would be a much higher than normal reading.
COMMISSIONER AHEARN~: You mentioned in the report about the 12DO millirem per hour reading in the helicopter.
That definitsly did happen.
That was from a licensee-hired helicopter.
He also had a 3000 millirem per hour.
MR. GIBSON: That-'s true.
That was on the 29th, the afternoon of the 29th.
COMMISSIONER BRADFORD: What happened to that r.eading?
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. 11 12 lJ 14 15 16 17 18 19 20 21 22 23 24 25 126 It-'s in your chrono.logy, but it-'s not in the r_eport.itself.
MR. GIBSON.: I know it-'s in the summary and_th.e summary was written from the reports.
So itJs probably in the report.
reading?
C0MMI.SSI0NER GILINSKY: Was NRC notified of that CO MMI.SSI0NER AHEARNE: I remember the 12.00.
MR. GIBSON.: I donJt believe we were.
COMMISSIONER GILINSKY: Because that certa.inly was
~ pretty strong reaction the following day to the 1200 millirem per hour
- MR. GIBSON: Tom, do you have something to add to that?
VOICE.: I believe that reg1on 1 was notified that it was 3 000.
Co MM I.SSI ONER GILl NSKY: And did not transmit that?
COMMISSIONER AHEARNE.: I see a nod there.
The fe.llow in the yellow shirt in front, it was?
reading.
V0I C!::: \\"le were notified.
COMMISSIONER AHEARNE: Region VOICE: We were aware of that.
was notif.i.ed.
COMMISSIONER AHEARNE: You did transmit that.
VOICE.: Yes, we did.
vfo had an instantaneous COMMISSIONER AHEARNE.: But you did transmit Lt down to
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9 10 J 1 12 13 14 1 5 16 17 18 19 20 21 22 23 2-4 25 127 Bethesda.
You wouldn.,t know~to whom?
VOICE: No.
(Laughter.)
MR. GIBSON.: Rather than go thr_ough and summarize the environmental readings,. which we did at the last briefing, I.,11 stop here, unless there are further questions.
CD)JkI SSHE*JER 3RADFORD: li _it was transmitted down to Bethesda, it was impossible, ultimately, to get more or less what happened to it.
MR. STELLO: Presumably, it should be possible.
MR. MOSELEY: Mr. Chairman. could I try to run very quickly --
CHAIRMAN HENDRIE: Please do. very quickly.
MR. /M_)SELEY: Through tf)e potential item*s of non-cor;ipliance and ;::ioint out that.these are. things that we will be evaluating, as Vic talked about sarlier, and there may be some that w.i 11 be added to this list as we have discussed here today.
(Slide.)
c~ ths first slide, all of these items were items that occurred before the accident.
And I won.,t spend any more time on that slide.
Go to the next slide.
CS l i de * )
And in fact, on this slide, through Item 10, those were things that occurred prior to the accideht.
6283.09.8 esh 2
Next slide, please.
(Slide. )
128 3
COMMISSIONER GILINSKY: Can you tell us which ones 4
of these you think are of most significance?
5 MR. MOSELEY: No, sir.
We..,r.e not prepare.cl to do 6
that at thls time.
7 COMMISSIONER AHEARNE: Could you say which ones of 8
these you would have expected I&E to heve picked up in its 9
inspection?
10 MR. MOSELEY.: I couldn..,t give you a real good' J l discussion of that.
If you like, we can come back later.
12 MR. STEUO-: There..,s an easier way.
Th.e first slide, 13 and I think part *of the seconj, cover items prior to the i 4, accident, only those, *or even in that potBntial category.
15 COMMISSIONER AHEARNE: That..,s wh.at l..,m saying.
16 MR. STELLO.: All of those are potentially items that 17 could have been covered.
18 COMMISSIONER AHEARNE.: I asked that, I think, 19 slightly di1ferently. Wouldn..,t you have expected it to have 20 been picked up?
21 CHAIRMAN HENDRIE: It depends on the inspection.
22 If you sent somebody up to look at QA records on a pipe 23 repair job, why, you wouldn..,t pick up numbers of these things.
24 If you were in for a heavier sweep of the place, why, you 25 would.
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.:.. _j 24 25 129 MR. MOSELEY.: It gets to be very speculative. We can go through and say, yes, these are our areas that we inspect and this is how much we inspect in this area.
Then you--'ve got to draw a conclusion.
COMMISSIONER AHEARNE-: I think what you--'re te 11 ing mei though, that you people, b~ing experienced in what l&E does~ there 1 s nothing on this list that you looked at and you said, our inspector should have caught that.
MR. M.OSELEY.: There--'s nothing on this list.
1-"'d put it another way.
There~s nothing on this list that *is not subject to being caught by our inspect~on program
- CcH:MLSSIOJ~ER AHEARNE: Or however.
That stuck out like a sore thumb that. you rea.11 y would have expected to have c.aught.
COMMISSIONER BRADFO*RD~ Proceaur.es on the valves?
MR. STELLO: Yes.
r_think the ones on the valves
- are a violation of a technical specification.
If somebody looked at that procedure, I.. think that that would be one I would expect.
COMlv'iI SSIONER AHEARNE.: That--' s the kind of thing I was looking for.
MR. M.OSELEY: Okay.
Slide 4, please.
CS l i de.)
That finish es o.ff th.e potential it ems of non-compliance related to the operational aspects.
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9 JO J I 12 j 3 14 15 16 17 18 19 20 21 22 23 24 25 Slide 5., please.
(Slide.)
130 All of the items on this slide *relate to things you/ve heard 9 things that occurred prior to the accident.
Next slide, please.
(Slide.)
And 9 indeed, down through item 5, which was the
.first.item on this slide, occurred prior to the accident.
The remaining items in this list -
the next slide, please.
(Slide.)
Are all things that related to events that occurred.
COMMISSIONER AHEARN.::: I gather that. you don..,t want us to focus part 1icularly.
MR. MOSELEY:' I..,m willing to focus on any that you have time to discuss.
CO MMLSS LONER GIL I NSKY: Let me ask you about one point. T~at is, the off-site measurements.
In the su~~ary, you say the licensee..,s on-site and off-site survey team perform surveys in appropriate areas in general, appropriate areas at appropriate times.
You then go on to say that they didn..,t perform any surveys.
COMMI.SSIOi-.J"Eii AHEARNE: At t_oo critical times.
COMMISSIONER GILINSKY: At too critical times when
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- 20 21 22 23 24 25 131 most of the releases took place.
MR. GIBSON.: Let me first.chara.cterize what the surveys we re.
They we re dose rate measurements or exposur.e rate measurements in th.e field that were not for th.e purpose of assessing cumulative dose to the public, but for determining the magnitude of the release and to determine if immediate protective actions were necessary.
Now with that in.m.ind, the investigat.ors looked at meteorology that existed d~ring the accident to determine if there were periods of time when the plume was weil defined; that.is, where the wind seems to be blowing at a reasonable velocity in a constant direction for a period of time.
And durin9 those int.erv2ls of time, did,the team make mea~urements where the plume was, or did he make his measurements somewhere else?
We did find that the two intervals of time listed that the licensee did not do a good enough job making measurements of the plume.
COMMI.SS.IONER GILINSKY: I thought you sa.id no off-site measurements at all during this p.eriod?
MR. GIBSON: In the plume, I think it says.
ls that correct.
COMMISSIONER GILINSKY: In the plume.
That-'s r.ight.
Sorry.
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9 10 J l 12 13 14 15 16 17 1 8 19 20 21 22 23 24 25 132 COMMISSIDNER AHEARNE.: So he was making off-sit.e measurements?
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COMMISSIONER AHEARNE: We he tracking the plume?
MR. GIBSON: The helicopter was used to track the plume. I donJt know whether it was used concurrently during this time period.
Do you know, Tom?
VOICE: During this particular time 9 no, the helicopter was not used.
The licensee focused primarily on performing surveys at known locations, known landmarks that he would relay a result from that point.
There was some plume-tracking done, but the major emphasis was on performing surveys at fixed points.
A team was dispatched to a fixed point-where they predicted where
- the plume was very dense.
MR. MOSELEY: Could we have slide 8, please?
(Slide.)
Tha things covered on this slide are related to overex~osures to individuals, the overexposure cases that are discussed in the report.
Next slide, slide 9, please.
(Slide.)
And this is true, also, of Item Eat the top and not true of Item F.
Th e th.in gs u n d er 1 4 on th i s s l id e a r e re 1 at e d to the
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9 10 J l 12 13 14 l 5 16 17 18 19 20 21 22 23 24 25 133 overexposure cases in terms of the limits themselYes.
And 15 --
Next slide, please.
(Slide.)
15 has to do with providing radiation monitoring to.monitor doses in those cases where exposures were obtained as in Item A.
Item B was not an overexposure. And number 16 is the final one of our potential items of non-compliance for consideration.
And that wraps it up, Mr. Chairman, unless someone has questions.
MR. STELLO: Mr. Chairman, let me comment that I know Mr. Moseley has gone through the last several slides very quickly.
I. think that it is appropriate _that we do this because I donJt believe we.l're prepared 'to discuss the merits.
As I indicated at the outset, I think considerably more time and thought is required to look at the real situation which you have and whether or not an item of non-compliance is really appropriate in light of the circumstances that they were working with.
And I am not prepared in any way to debate the merits of any of these at this time.
Some seem, IJm sure, to each of us more obvious than others.
Clearly, this is an item of non-compliance.
But until you really have had some time to think about it, I
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10 l 1 12 i3 14 15 16 17 18 19 20 21 22 23 24 25 134 just donJt think it 1 ~ appropriate to argue that point now.
Nor do I think it really serves any useful purpose trying to move quickly to get a notice of violation out and take enforcement action with this licensee.
accident.
Clearly, I. think he 1 s well aware that he had an CHAIRMAN HENDRIE: He has a problem.
COMMISSIONER BRADFORD: What is the process that you vii 11 go through now on these potentia.l areas of non-compliance?
MR. STELLO:
I said at the outset -- perhaps you weren-'t here that my intent is not less than 60 days for sure, to try to deal with each of the potential items of non-cornpliance,_try to make some kind of a decision*~*
But it isn1 t clear to me that because of the issues of what were the real issues on safety or the underlying facts relating to the total pitture, whether it1 s appropriate to even wait for some or many of these until some other investigations 2re over.
But assuming that all that-'s behind us, the
.classical process will follow.
Vje-'ll decide on non-compliance, prepare a notice of violation, if that-'s appropriate, send it to the licensee.
And if civil penalties are appropriate, include those, and then follow up with whatever action we need from that point on.
7
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. 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 135 COMMISSIONER BRADFORD: What are the criteri~ that you use,.assum.ing that you come to a point where you can say fairly clearly, this *is not consistent with the tech specs?
Then what criteria do you use in determin.ing whether to pursue the matter further?
MR. STELLO: It fo.llows the briefing we had.the last time that you were here on the enforcBment policy.
A ranking, depending on the issues associated with the --rE~m of non-compliance as to its sev.erity.
And it will receive a number of points, depending on which it is
- COMMISSIONER BRADFORD: Or on up through to a higher citation?
MR. STELLO.: Yes, to try to reach that decision.
COMMISSIOi'JER BRADFORD: The po.int sy.stem may not mean a whol.e lot.
MR. MOSELEY.: ItJs a guide, guiding our judgment.
We have not used it as an absolute indicator, jn any case.
COMMISSIONER BRADFORD: But I gather it works in terms of points per time period and the chances of there being very many more points at a particular time period.
MR. STELLO: Commissioner Bradford, de a Ling with the issue involved ~nan accident is not.something for which that sys tern was set up for.
And that., s, again, why I just want more time.
This is not a classical enforcement procedure, in my view, and 1~11 need a little bit more time because the
6283.09.16 i
136 whole process wasn-'t set up to handle this.
2 CHAIRMAN HENDRIE: I had a question on the 3
radiological side.
Does anybody offhand have an estimate 4
of what the occupational exposure has been to date?
'.)
6 7
MR. STEU0: Integrated?
MR. GIBSON.: What is the man-rem?
V0JCE: The man-rem +/-or the first three days was 8
estimated at 104.
That-'s _just for the first three-day 9
period.
~e did not go beyond that point in trying to 10 estimate the cumulative man-rem to date.
l l CHAIRMAN HENDRIE: Okay.
12 M:=?. STEU0: Do you have any idea if the first three 13 days were clearly typical or things are considerably better i4 s'ince then?
15 VOICE*: The man-rem accumulation *rate will increase 16 as the recovery operations go on.
17 MR. STELLO.: With an increased number of people.
18 CHAIRMAN HENDRIE.: Yes, I expect it.
I was just 19 curious as to whether it~s up into the several thousand 20 person-rem level yet, or even above.
21 All right, other questions?
22 COMi1USSI0NER AHcARNE: Vic, you have now a lessons 23 learned effort underway.
A~d I would imagine that this would 24 be a major part of it.
Is that correct?
25 MR. STEU0.: Yes.
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. 283. 09. 1 7 2
137 COMM I SST.ONER AHEARNE.: So that when the lessons learned will focus. not just on what I&E in Bethesda does in 3
this. but also any possible changes in regulations that we 4
might be proposing as a result.
Is that correct?
6 MR. STELLO: Regulations or orders *. There might be 7
suggestions that we choose to send over to Mr. Denton 8
suggesting some additional licensing requirements. That may 9
be prudent,.which wonJt require a change in regulations.
JO Those two.
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CHAI RMA:'l rlENDRI E: Thank you very mu ch.
.I c orrnnend the audience as we.11 for a long morning in a hot rdo~. Your 13 stamina su~prises ~e
- 14 C~hefeupon, at 12:45 p.m., the hearing was 1 5
. adj our n e d * )
16 17 18 19 20 21 22 23 24 25